Provider Demographics
NPI:1255394425
Name:KIZER, LEWIS B (OD)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:B
Last Name:KIZER
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:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-0548
Mailing Address - Country:US
Mailing Address - Phone:731-686-8642
Mailing Address - Fax:731-686-7622
Practice Address - Street 1:2081 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3011
Practice Address - Country:US
Practice Address - Phone:731-686-8642
Practice Address - Fax:731-686-7622
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726103Medicaid
TN3594690Medicaid
TN4748380001Medicare NSC
TNT61203Medicare UPIN
TN3726103Medicare ID - Type Unspecified
TN3726103Medicaid