Provider Demographics
NPI:1578529863
Name:JOHNSON, GREGORY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
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 1:305 EAST 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130
Mailing Address - Country:US
Mailing Address - Phone:920-766-4656
Mailing Address - Fax:920-766-4659
Practice Address - Street 1:305 EAST 12TH STREET
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130
Practice Address - Country:US
Practice Address - Phone:920-766-4656
Practice Address - Fax:920-766-4659
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0028536207Q00000X
WI28536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31483400Medicaid
WI31483400Medicaid
WIE16109Medicare UPIN
E16109Medicare UPIN