Basic Information
| Provider Information | |||||||||
| NPI: | 1912090143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 42ND AVE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288648049 | ||||||||
| FaxNumber: | 2288647655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 42ND AVE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288648049 | ||||||||
| FaxNumber: | 2288647655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 02/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 14710R | LA | Y | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 17858 | MS | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1136697 | 05 | LA | MEDICAID |