Provider Demographics
NPI:1093752115
Name:LEWIS, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
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 639
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-0639
Mailing Address - Country:US
Mailing Address - Phone:601-645-5221
Mailing Address - Fax:
Practice Address - Street 1:451 BANK ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-6000
Practice Address - Country:US
Practice Address - Phone:601-888-3421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS9630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0115504Medicaid
LA1339563Medicaid
MS0115504Medicaid
110001623Medicare ID - Type Unspecified