Provider Demographics
NPI:1659339919
Name:JOHNSON, TAD MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:TAD
Middle Name:MARK
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 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7100
Mailing Address - Fax:608-756-4700
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7100
Practice Address - Fax:608-756-4700
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25307207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIJOHNSTADOtherMERCYCARE INSURANCE
WI1659339919OtherBCBSWI
WI1659339919Medicaid
WI30661900Medicaid
WI000002624-0004Medicare ID - Type Unspecified
WI541760895Medicare PIN
WI1659339919OtherBCBSWI