Provider Demographics
NPI:1629030168
Name:GRAVELY, LEWIS WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:WILLIAM
Last Name:GRAVELY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 CARRIAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-253-1210
Mailing Address - Fax:304-255-4040
Practice Address - Street 1:413 CARRIAGE DRIVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-253-1210
Practice Address - Fax:304-255-4040
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11494207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0095205000Medicaid
A72004Medicare UPIN
WV0095205000Medicaid
WV0527820001Medicare NSC