Provider Demographics
NPI:1912923442
Name:LEWIS, ANTHONY EVAN (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:EVAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A
Other - Middle Name:EVAN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-3628
Practice Address - Fax:423-230-8502
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249890207R00000X
TN24434207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100109560Medicaid
VA1912923442Medicaid
TN1510062Medicaid
NC1912923442Medicaid
TNQ002676Medicaid
TN103I118474Medicare PIN
VA1912923442Medicaid
TN1510062Medicaid
NC1912923442Medicaid