Healthcare Provider Details

I. General information

NPI: 1003043506
Provider Name (Legal Business Name): MATTHEW WESLEY LEWIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 E LAKE BLVD SUITE 201
VANCLEAVE MS
39565-6770
US

IV. Provider business mailing address

6300 E LAKE BLVD
VANCLEAVE MS
39565-6770
US

V. Phone/Fax

Practice location:
  • Phone: 228-206-2263
  • Fax: 228-206-1192
Mailing address:
  • Phone: 228-206-2263
  • Fax: 228-206-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number23036
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number23036
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: