Healthcare Provider Details

I. General information

NPI: 1568437762
Provider Name (Legal Business Name): CARLOS M LEWIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 AVON ST
FAYETTEVILLE NC
28304
US

IV. Provider business mailing address

1319 AVON ST
FAYETTEVILLE NC
28304-4423
US

V. Phone/Fax

Practice location:
  • Phone: 910-729-6552
  • Fax:
Mailing address:
  • Phone: 910-729-6552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2018-00317
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number5101008932
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: