Provider Demographics
NPI:1073536132
Name:LEWIS, JOHN WILLIAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:512 LEVEE STREET
Mailing Address - Street 2:P. O. BOX 310
Mailing Address - City:ROSEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38769-0310
Mailing Address - Country:US
Mailing Address - Phone:662-759-3728
Mailing Address - Fax:662-759-6771
Practice Address - Street 1:512 LEVEE STREET
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MS
Practice Address - Zip Code:38769-0310
Practice Address - Country:US
Practice Address - Phone:662-759-6806
Practice Address - Fax:662-759-6771
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS09592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013560Medicaid
MS00013560Medicaid