Provider Demographics
NPI:1912090143
Name:LEWIS, ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2666
Mailing Address - Country:US
Mailing Address - Phone:228-864-8049
Mailing Address - Fax:228-864-7655
Practice Address - Street 1:1245 42ND AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2666
Practice Address - Country:US
Practice Address - Phone:228-864-8049
Practice Address - Fax:228-864-7655
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14710R207N00000X
MS17858207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1136697Medicaid
LA1136697Medicaid
LA4E775Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER