Basic Information
Provider Information | |||||||||
NPI: | 1063472967 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | JEFFERY | ||||||||
MiddleName: | DUN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 993D JOHNSON FERRY RD | ||||||||
Address2: | STE 440 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042570799 | ||||||||
FaxNumber: | 4045032280 | ||||||||
Practice Location | |||||||||
Address1: | 993D JOHNSON FERRY RD | ||||||||
Address2: | STE 440 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042570799 | ||||||||
FaxNumber: | 4045032280 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2006 | ||||||||
LastUpdateDate: | 03/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 041873 | GA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 2134940 | 01 |   | AETNA HMO POS | OTHER | 1422312 | 01 |   | UNITED HEALTH CARE | OTHER | 000709497H | 05 | GA |   | MEDICAID | 52508068010 | 01 |   | BLUE CHOICE PROVIDER IDS | OTHER | 5433953006 | 01 |   | CIGNA | OTHER | 5757428 | 01 |   | AETNA MC PPO | OTHER | 080685 | 01 |   | BLUE CHOICE FAC INS | OTHER | 1789 | 01 |   | KAISER | OTHER |