Provider Demographics
NPI:1407976012
Name:WALKER, JOHNNY JR
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:WALKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOHNNY
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4523 W MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3448
Mailing Address - Country:US
Mailing Address - Phone:414-445-3373
Mailing Address - Fax:414-873-9296
Practice Address - Street 1:4523 W MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3448
Practice Address - Country:US
Practice Address - Phone:414-445-3373
Practice Address - Fax:414-873-3299
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIW4264205140705172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver