Provider Demographics
NPI:1639117476
Name:LEWIS, LARRY S (OD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:S
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1547
Mailing Address - Country:US
Mailing Address - Phone:727-322-7920
Mailing Address - Fax:727-322-7921
Practice Address - Street 1:790 CONCOURSE PKWY S
Practice Address - Street 2:SUITE 200
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-6114
Practice Address - Country:US
Practice Address - Phone:407-767-6411
Practice Address - Fax:407-767-8160
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078800700Medicaid
FL1125957Medicare PIN
FLT84252Medicare UPIN
FL078800700Medicaid
FL410028807Medicare PIN
FL19447WMedicare PIN
FL19447VMedicare PIN