Provider Demographics
NPI:1417989559
Name:JOHNSON, GWEN A (MD)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:3055 HUBERTUS RD
Practice Address - Street 2:
Practice Address - City:HUBERTUS
Practice Address - State:WI
Practice Address - Zip Code:53033
Practice Address - Country:US
Practice Address - Phone:262-628-9000
Practice Address - Fax:262-628-7255
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31555100Medicaid
WIP00836847OtherRR MEDICARE
E87791Medicare UPIN
WI01994-0040Medicare PIN
WIP00836847OtherRR MEDICARE