Healthcare Provider Details

I. General information

NPI: 1891152641
Provider Name (Legal Business Name): STEPHEN WILLIAM LEWELLIS M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 05/02/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 CORPORATE AVE
PLOVER WI
54467-3566
US

IV. Provider business mailing address

3002 N 7TH ST
WAUSAU WI
54403-3003
US

V. Phone/Fax

Practice location:
  • Phone: 715-391-9774
  • Fax: 917-277-4883
Mailing address:
  • Phone: 715-391-9774
  • Fax: 917-277-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number65601
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number75498-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: