Provider Demographics
NPI:1396872933
Name:LEWIS, LATASHA M (MD)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:MONIQUE
Other - Last Name:MCCAULLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5798
Mailing Address - Country:US
Mailing Address - Phone:504-896-3952
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5798
Practice Address - Country:US
Practice Address - Phone:504-896-3952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700462208000000X
IN01061173A2080P0203X
NC2010-004342080P0203X
LA3207502080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04205361Medicaid
NC5916120Medicaid
MS04205361Medicaid
NC5916120Medicaid