Provider Demographics
NPI:1306819305
Name:LEWIS, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:11649 N PORT WASHINGTON RD STE 114
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3461
Mailing Address - Country:US
Mailing Address - Phone:262-235-3800
Mailing Address - Fax:262-236-9726
Practice Address - Street 1:11649 N PORT WASHINGTON RD STE 114
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3461
Practice Address - Country:US
Practice Address - Phone:262-235-3800
Practice Address - Fax:262-236-9726
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32308200Medicaid
683750185Medicare PIN
WI32308200Medicaid