Provider Demographics
NPI:1033248976
Name:LEWIS, LAWRENCE K (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:K
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:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-0552
Mailing Address - Country:US
Mailing Address - Phone:706-342-1561
Mailing Address - Fax:706-342-3917
Practice Address - Street 1:1010 BARCLAY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-4621
Practice Address - Country:US
Practice Address - Phone:706-342-1561
Practice Address - Fax:706-342-3917
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00011217CMedicaid
GA00011217CMedicaid