Provider Demographics
NPI:1295093086
Name:LEWIS, DEMETRIUS VINDE
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:VINDE
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 PAGODA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-4439
Mailing Address - Country:US
Mailing Address - Phone:706-593-8727
Mailing Address - Fax:
Practice Address - Street 1:1314 PAGODA DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-4439
Practice Address - Country:US
Practice Address - Phone:706-593-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN052272164W00000X
GANIIA005224376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
No164W00000XNursing Service ProvidersLicensed Practical Nurse