Provider Demographics
NPI:1649233255
Name:JOHNSON, NIEL A (MD)
Entity Type:Individual
Prefix:
First Name:NIEL
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 1:16985 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5909
Mailing Address - Country:US
Mailing Address - Phone:262-641-8400
Mailing Address - Fax:910-369-2874
Practice Address - Street 1:16985 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5909
Practice Address - Country:US
Practice Address - Phone:262-641-8400
Practice Address - Fax:910-369-2874
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS429844207P00000X
WI35197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103264Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER