Provider Demographics
NPI:1699744722
Name:LEWIS, LARRY GLEN (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:GLEN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:993 D JOHNSON FERRY RD
Mailing Address - Street 2:STE 440
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-257-0799
Mailing Address - Fax:404-503-2280
Practice Address - Street 1:993 D JOHNSON FERRY RD
Practice Address - Street 2:STE 440
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-257-0799
Practice Address - Fax:404-503-2280
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0523572080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134940OtherAETNA HMO POS
5433953006OtherCIGNA
REF000087396OtherMEDICAID REFERENCE PROVID
000709497HOtherMEDICAID PROVIDER NUMBER
52508068010OtherBLUE CHOICE PROVIDER ID
GA000981901AMedicaid
5757428OtherAETNA MC PPO PIN NUMBER
1422312OtherUNITED HEALTH CARE
080685OtherBLUE CHOICE FAC INSURANCE
1789OtherKAISER