Provider Demographics
NPI:1801802046
Name:LEWIS, MICHELLE D (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:D
Other - Last Name:JANOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-686-9674
Practice Address - Street 1:3935 N. LIGHTNING DRIVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7890
Practice Address - Country:US
Practice Address - Phone:920-968-1790
Practice Address - Fax:920-968-1794
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53110-020207N00000X, 207N00000X
RIMD11804207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI53730-020OtherSTATE LICENSE
WI1801802046Medicaid
WIBL9236034OtherDEA
CO69254524Medicaid
WIBL9236034OtherDEA
412474OtherBLUE CHIP
COCO300399Medicare PIN
WIBL9236034OtherDEA
WI53730-020OtherSTATE LICENSE
I37340Medicare UPIN