Provider Demographics
NPI:1265469738
Name:LEWIS, AUGUSTINE WARNER III
Entity Type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:WARNER
Last Name:LEWIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7864 RICHMOND TAPPAHANNOCK HWY
Mailing Address - Street 2:
Mailing Address - City:AYLETT
Mailing Address - State:VA
Mailing Address - Zip Code:23009-3056
Mailing Address - Country:US
Mailing Address - Phone:804-746-1677
Mailing Address - Fax:804-769-3170
Practice Address - Street 1:7864 RICHMOND TAPPAHANNOCK HWY
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3056
Practice Address - Country:US
Practice Address - Phone:804-746-1677
Practice Address - Fax:804-769-3170
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101019901207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05698OtherGROUP PTAN
204502OtherANTHEM (BC/BS OF VA)
254728OtherMAMSI
5606468OtherAETNA - LIFE
5606468OtherAETNA - HMO
VA005811694Medicaid
080123285OtherRAILROAD MEDICARE
1471267OtherCIGNA
79134OtherSOUTHERN HEALTH SERVICES
254728OtherMAMSI