Provider Demographics
NPI:1871679001
Name:LEWELLEN, THOMAS L SR (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:LEWELLEN
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:105 W WATERMAN
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639-0128
Mailing Address - Country:US
Mailing Address - Phone:870-382-1188
Mailing Address - Fax:870-382-4049
Practice Address - Street 1:105 W WATERMAN ST
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-2139
Practice Address - Country:US
Practice Address - Phone:870-382-1188
Practice Address - Fax:870-382-4049
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN5891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102105003Medicaid
AR53137Medicare ID - Type Unspecified
AR102105003Medicaid