1508843442 NPI number — DANTE NEISONE LEWIS MD

Table of content: DANTE NEISONE LEWIS MD (NPI 1508843442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508843442 NPI number — DANTE NEISONE LEWIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
DANTE
Provider Middle Name:
NEISONE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508843442
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 W WEBB AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27217-3706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-228-8316
Provider Business Mailing Address Fax Number:
336-227-9750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3940 ARROWHEAD BLVD STE 270
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEBANE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27302-7637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-563-0202
Provider Business Practice Location Address Fax Number:
919-563-0242
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  2019-00846 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30392 . This is a "SC MEDICAL LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 4001444 . This is a "CIGNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 9630227 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 20069023 . This is a "SELECT HEALTH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: AA23878552 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 2019-00846 . This is a "NC MEDICAL LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 303923 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18500 . This is a "EVOLUTIONS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5908146 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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