Provider Demographics
NPI:1508075409
Name:MACIAS TEJADA, JONNY ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:JONNY
Middle Name:ALEXANDER
Last Name:MACIAS TEJADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JONNY
Other - Middle Name:A
Other - Last Name:MACIAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1020 N 12TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1308
Mailing Address - Country:US
Mailing Address - Phone:414-219-7300
Mailing Address - Fax:414-219-7632
Practice Address - Street 1:1020 N 12TH ST STE 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1308
Practice Address - Country:US
Practice Address - Phone:414-219-7300
Practice Address - Fax:414-219-7632
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52098-020207QG0300X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100005725Medicaid