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General NPI Number Information
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NPI Number | 1699744722
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Entity Type | Individual
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Provider Name | LARRY GLEN LEWIS MD
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Gender | Male
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 03/08/2012
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Provider Practice Location Address
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Address Line | 993 D JOHNSON FERRY RD STE 440
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City | ATLANTA
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State | GA
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Zip | 30342
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Country | US
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Telephone | 404-257-0799
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Fax | 404-503-2280
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Provider Business Mailing Address
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Address Line | 993 D JOHNSON FERRY RD STE 440
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City | ATLANTA
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State | GA
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Zip | 30342
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Country | US
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Telephone | 404-257-0799
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Fax | 404-503-2280
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number | 052357
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License Number State | GA
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