Provider Demographics
NPI:1699701524
Name:LEWIS, DENNIS M (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
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 1:1116 11TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-3608
Mailing Address - Country:US
Mailing Address - Phone:386-362-0820
Mailing Address - Fax:386-362-1817
Practice Address - Street 1:1116 11TH ST SW
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064
Practice Address - Country:US
Practice Address - Phone:386-362-0820
Practice Address - Fax:386-362-1817
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5754A208600000X
FLME56099208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01731293Medicaid
FLJK189ZOtherUPIN
WYW10449Medicare ID - Type Unspecified