Provider Demographics
NPI:1215996723
Name:NOTTLESON, STEVEN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:LEE
Last Name:NOTTLESON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2782 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6204
Mailing Address - Country:US
Mailing Address - Phone:920-562-0408
Mailing Address - Fax:920-494-3705
Practice Address - Street 1:1545 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1334
Practice Address - Country:US
Practice Address - Phone:715-735-3012
Practice Address - Fax:715-735-3636
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1960-035152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871667220OtherGROUP NPI
39-1548019OtherTAX ID
DG8179OtherGROUP PTAN
WI38523200Medicaid
WIP00609894Medicare PIN
WI87872Medicare PIN
U32085Medicare UPIN
DG8179OtherGROUP PTAN