Healthcare Provider Details

I. General information

NPI: 1023458304
Provider Name (Legal Business Name): EVAN MICHAEL LEWIS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 REINHARDT COLLEGE PKWY STE 10
CANTON GA
30114-5295
US

IV. Provider business mailing address

1975 HIGHWAY 54 W STE 205
PEACHTREE CITY GA
30269-4794
US

V. Phone/Fax

Practice location:
  • Phone: 470-274-7763
  • Fax: 770-213-4152
Mailing address:
  • Phone: 770-716-8732
  • Fax: 770-487-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number788
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: