Provider Demographics
NPI:1578854659
Name:LLEWELLYN, MICHAEL (MD, PH D)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LLEWELLYN
Suffix:
Gender:M
Credentials:MD, PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N SEGOE RD APT 215
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3156
Mailing Address - Country:US
Mailing Address - Phone:650-862-8556
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-8340
Practice Address - Fax:608-263-0682
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI651362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program