Provider Demographics
NPI:1265489181
Name:JOHNSON, MELISSA KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:KATHLEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:KATHLEEN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1836 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5429
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125043239208600000X
SD5904208600000X
WI72696208600000X
WI72696-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00419564Medicare PIN
SDS101165Medicare PIN