Provider Demographics
NPI:1508870304
Name:LEWIS, BENNETT ALAN
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:ALAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BENNETT
Other - Middle Name:ALAN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1501 PRESIDENTIAL WAY
Mailing Address - Street 2:SUITE 20
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-1800
Mailing Address - Country:US
Mailing Address - Phone:561-471-2844
Mailing Address - Fax:
Practice Address - Street 1:1501 PRESIDENTIAL WAY
Practice Address - Street 2:SUITE 20
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-1800
Practice Address - Country:US
Practice Address - Phone:561-471-2844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS6671OtherLICENSE
FL65-1007874OtherTAX ID
FLE44674Medicare UPIN