Provider Demographics
NPI:1407948763
Name:JOHNSON, PETER HAAN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:HAAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE STE 108
Mailing Address - Street 2:PROHEALTH CARE REGIONAL CANCER CENTER
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-5350
Mailing Address - Fax:
Practice Address - Street 1:721 AMERICAN AVE STE 108
Practice Address - Street 2:PROHEALTH CARE REGIONAL CANCER CENTER
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8751207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176675001Medicaid
8C1247Medicare ID - Type Unspecified
TX176675001Medicaid
I11457Medicare UPIN