Basic Information
| Provider Information | |||||||||
| NPI: | 1124145040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | LYNNE BUTENHOFF | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 SCHEURING RD | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541151067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209640229 | ||||||||
| FaxNumber: | 9206869674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2007 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD430734 | PA | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 4301105435 | MI | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 50518-20 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 382000020 | 01 | WI | MEDICARE | OTHER | 171400016 | 01 | WI | MEDICARE | OTHER | P00720349 | 01 | WI | RAILROAD MEDICARE | OTHER | FC0175465 | 01 | WI | DEA | OTHER | 1124145040 | 05 | WI | MEDICAID | 50518-020 | 01 | WI | STATE LICENSE | OTHER |