Provider Demographics
NPI:1063432045
Name:LEWIS, CHARLES ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CARRABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:32322-5053
Mailing Address - Country:US
Mailing Address - Phone:850-697-4436
Mailing Address - Fax:
Practice Address - Street 1:1224 OCALA RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32304-1548
Practice Address - Country:US
Practice Address - Phone:850-576-2129
Practice Address - Fax:850-576-9602
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00570392083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080157777OtherRAILROAD (MEDICARE)
FL056965800Medicaid
FLK1396Medicare ID - Type Unspecified
FLD08172Medicare UPIN