Provider Demographics
NPI:1003043506
Name:LEWIS, MATTHEW WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WESLEY
Last Name:LEWIS
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 1:6300 E LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-206-2263
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:6300 E LAKE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-6770
Practice Address - Country:US
Practice Address - Phone:228-206-2263
Practice Address - Fax:228-206-1192
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23036207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine