Provider Demographics
NPI:1467484030
Name:JOHNSON, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
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 1:3916 N INTERTECH CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913
Mailing Address - Country:US
Mailing Address - Phone:920-996-1000
Mailing Address - Fax:920-997-8302
Practice Address - Street 1:3916 N INTERTECH CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913
Practice Address - Country:US
Practice Address - Phone:920-996-1000
Practice Address - Fax:920-997-8302
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33994-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31904500Medicaid
P00085735OtherRR MEDICARE
WI000445380Medicare ID - Type Unspecified
F52166Medicare UPIN