Provider Demographics
NPI:1912956137
Name:LEWIS, MITCHELL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:L
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 1:1400 EASTSIDE RD
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-9800
Mailing Address - Country:US
Mailing Address - Phone:608-348-2331
Mailing Address - Fax:
Practice Address - Street 1:1400 EASTSIDE RD
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9800
Practice Address - Country:US
Practice Address - Phone:608-348-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50980-20207P00000X
CO35977207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34974100Medicaid
CO01359777Medicaid
WI34974100Medicaid
COX0578Medicare ID - Type Unspecified