Provider Demographics
NPI:1558362046
Name:LEWELLEN, DONALD R (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:LEWELLEN
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: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
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27021207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI037664001OtherADMINASTAR FEDERAL
WI30675000Medicaid
WI30675000Medicaid
WI037664001OtherADMINASTAR FEDERAL
WI180012122Medicare PIN