Provider Demographics
NPI:1861427825
Name:LEWIS, MARVIN (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 AUTUMN FERN TRL
Mailing Address - Street 2:PO BOX 2768
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-5155
Mailing Address - Country:US
Mailing Address - Phone:910-364-0970
Mailing Address - Fax:910-814-4063
Practice Address - Street 1:6750 OVERHILLS RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-8872
Practice Address - Country:US
Practice Address - Phone:910-436-2600
Practice Address - Fax:910-436-0588
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC33542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8951832Medicaid
NC8951832Medicaid