Provider Demographics
NPI:1497826796
Name:CUNNINGHAM, LEWIS NOLAN (DO)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:NOLAN
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 W MAIN ST.
Mailing Address - Street 2:STE. 21
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1058
Mailing Address - Country:US
Mailing Address - Phone:334-699-7900
Mailing Address - Fax:334-699-7901
Practice Address - Street 1:WIREGRASS CLINIC LLC
Practice Address - Street 2:4300 WMAIN ST, STE 21
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36116
Practice Address - Country:US
Practice Address - Phone:334-793-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7039208800000X
SD4405208800000X
OH8878208800000X
MS25020208800000X
ALDO.1166208800000X
AL1166208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D98806Medicare UPIN