Provider Demographics
NPI:1417971433
Name:JOHNSON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WI
Mailing Address - Zip Code:53167-0386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WI
Practice Address - Zip Code:53167-0386
Practice Address - Country:US
Practice Address - Phone:262-331-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist