Provider Demographics
NPI:1437144417
Name:EYE CLINIC OF MANITOWOC, S.C.
Entity Type:Organization
Organization Name:EYE CLINIC OF MANITOWOC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST/VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEWELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-684-4429
Mailing Address - Street 1:PO BOX 1900
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1900
Mailing Address - Country:US
Mailing Address - Phone:920-684-4429
Mailing Address - Fax:920-684-6892
Practice Address - Street 1:4801 EXPO DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-9341
Practice Address - Country:US
Practice Address - Phone:920-684-4429
Practice Address - Fax:920-684-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 156FX1800X
WI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICO8042OtherRAILROAD MEDICARE
WI21284400Medicaid
WI21284400Medicaid
WICO8042OtherRAILROAD MEDICARE