Provider Demographics
NPI:1184710857
Name:LEWIS, MYRON KEITH (M D)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:KEITH
Last Name:LEWIS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:292 INDUSTRIAL BLVD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036
Mailing Address - Country:US
Mailing Address - Phone:478-783-2297
Mailing Address - Fax:478-783-2296
Practice Address - Street 1:292 INDUSTRIAL BLVD.
Practice Address - Street 2:SUITE 102
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036
Practice Address - Country:US
Practice Address - Phone:478-783-2297
Practice Address - Fax:478-783-2296
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA018922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BDNCLMedicare ID - Type Unspecified
GAD40456Medicare UPIN