Healthcare Provider Details

I. General information

NPI: 1063432045
Provider Name (Legal Business Name): CHARLES ALAN LEWIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 OCALA RD
TALLAHASSEE FL
32304-1548
US

IV. Provider business mailing address

602 RIVERVIEW DR
CARRABELLE FL
32322-5053
US

V. Phone/Fax

Practice location:
  • Phone: 850-576-2129
  • Fax: 850-576-9602
Mailing address:
  • Phone: 850-697-4436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberME0057039
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: