Provider Demographics
NPI:1578978805
Name:LEWIS, VANCE PERRY (OD)
Entity type:Individual
Prefix:DR
First Name:VANCE
Middle Name:PERRY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 W SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4903
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-893-8172
Practice Address - Street 1:10485 W MCDOWELL RD STE 103
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4914
Practice Address - Country:US
Practice Address - Phone:480-908-1001
Practice Address - Fax:480-908-1002
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ923758Medicaid
AZZ167524Medicare PIN
AZZ162079Medicare PIN
AZZ162076Medicare PIN
AZZ162074Medicare PIN
AZZ162075Medicare PIN
AZZ167526Medicare PIN
AZZ167525Medicare PIN
AZZ162077Medicare PIN
AZZ162078Medicare PIN
AZZ167523Medicare PIN
AZZ167521Medicare PIN