Provider Demographics
NPI:1326070962
Name:LEWIS, MARTIN GWENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:GWENT
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 1:6501 PASADENA AVENUE, NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710
Mailing Address - Country:US
Mailing Address - Phone:727-343-3545
Mailing Address - Fax:727-343-3681
Practice Address - Street 1:6501 PASADENA AVENUE, NORTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710
Practice Address - Country:US
Practice Address - Phone:727-343-3545
Practice Address - Fax:727-343-3681
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43645207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257906500Medicaid
FLE65758Medicare UPIN
FL257906500Medicaid