Basic Information
| Provider Information | |||||||||
| NPI: | 1194762765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 136 N MAIN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | THIENSVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530921606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622423369 | ||||||||
| FaxNumber: | 2622423219 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 N MAIN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | THIENSVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530921606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622423369 | ||||||||
| FaxNumber: | 2622423219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 330004-020 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 33004-020 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31823100 | 05 | WI | MEDICAID |