Healthcare Provider Details

I. General information

NPI: 1124145040
Provider Name (Legal Business Name): LISA LYNNE BUTENHOFF CAMPBELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SCHEURING RD
DE PERE WI
54115-1067
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 920-964-0229
  • Fax: 920-686-9674
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD430734
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number4301105435
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number50518-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: