Provider Demographics
NPI:1629299730
Name:LEWIS, FREDRICK AUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:AUSTIN
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 1:22 PIN OAK LN
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-8201
Mailing Address - Country:US
Mailing Address - Phone:985-429-8412
Mailing Address - Fax:
Practice Address - Street 1:22 PIN OAK LN
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-8201
Practice Address - Country:US
Practice Address - Phone:985-429-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0101252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1110124Medicaid
LA1110124Medicaid
LAB54569Medicare UPIN