Provider Demographics
NPI:1710081393
Name:LEWIS, JOHN EDGAR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDGAR
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:65 MEDICAL PARK BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-8428
Mailing Address - Country:US
Mailing Address - Phone:318-484-2951
Mailing Address - Fax:318-484-2951
Practice Address - Street 1:65 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-8428
Practice Address - Country:US
Practice Address - Phone:318-484-2951
Practice Address - Fax:318-484-2951
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA3019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1970271Medicaid
LA1970271Medicaid
LAD84226Medicare UPIN