Provider Demographics
NPI:1497970560
Name:LEWIS, KEVAN G (MD)
Entity Type:Individual
Prefix:
First Name:KEVAN
Middle Name:G
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 1:2221 S WEBSTER AVE
Mailing Address - Street 2:STE 241
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2158
Mailing Address - Country:US
Mailing Address - Phone:920-965-0345
Mailing Address - Fax:920-273-6011
Practice Address - Street 1:3059 VOYAGER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8303
Practice Address - Country:US
Practice Address - Phone:920-965-0345
Practice Address - Fax:920-257-4559
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53110-20207N00000X
MN51745207N00000X
RILP00514207N00000X
WI53110-020207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNP00787809OtherRAILROAD MEDICARE
WI1497970560Medicaid
WI53110-020OtherSTATE LICENSE
MNENROLLEDMedicaid
MNENROLLEDMedicaid
WI382000024Medicare PIN
IAENROLLEDMedicaid