Provider Demographics
NPI:1568409878
Name:LEWIS, MICHAEL RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
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 1:4500 OLD PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2585
Mailing Address - Country:US
Mailing Address - Phone:228-865-7890
Mailing Address - Fax:228-868-7402
Practice Address - Street 1:4500 OLD PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2585
Practice Address - Country:US
Practice Address - Phone:228-865-7890
Practice Address - Fax:228-868-7402
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13326174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS060065909OtherMEDICARE SECONDARY PAYOR
MS00116618Medicaid
MS00116618Medicaid
MS640878169OtherTIN
MS640878169OtherTIN
MS060000187Medicare ID - Type Unspecified