Healthcare Provider Details

I. General information

NPI: 1053937995
Provider Name (Legal Business Name): IAN ZACHARY LEWIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3100
  • Fax: 262-532-9584
Mailing address:
  • Phone: 414-805-3100
  • Fax: 262-532-9584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number81109
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: