Provider Demographics
NPI:1336342591
Name:LEWIS, MICHAEL JESSE (IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JESSE
Last Name:LEWIS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 WAKULLA AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7085
Mailing Address - Country:US
Mailing Address - Phone:850-625-8999
Mailing Address - Fax:850-769-6760
Practice Address - Street 1:321 BULLFINCH RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32407-7012
Practice Address - Country:US
Practice Address - Phone:850-230-3236
Practice Address - Fax:850-230-3234
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman