Healthcare Provider Details

I. General information

NPI: 1972537041
Provider Name (Legal Business Name): WILLIE JAMES LEWIS SR. D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 POINDEXTER ST
JACKSON MS
39203-3048
US

IV. Provider business mailing address

128 POINDEXTER ST
JACKSON MS
39203-3048
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-0026
  • Fax: 601-355-0069
Mailing address:
  • Phone: 601-355-0026
  • Fax: 601-355-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number80062
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: