1710081393 NPI number — DR. JOHN EDGAR LEWIS M.D.

Table of content: DR. JOHN EDGAR LEWIS M.D. (NPI 1710081393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710081393 NPI number — DR. JOHN EDGAR LEWIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
JOHN
Provider Middle Name:
EDGAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1710081393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 MEDICAL PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
PINEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71360-8428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-484-2951
Provider Business Mailing Address Fax Number:
318-484-2951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 MEDICAL PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PINEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71360-8428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-484-2951
Provider Business Practice Location Address Fax Number:
318-484-2951
Provider Enumeration Date:
09/12/2006

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: 207N00000X , with the licence number:  3019 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1970271 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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