Provider Demographics
NPI:1669466231
Name:JOHNSON, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
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 1:3329 N RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1063
Mailing Address - Country:US
Mailing Address - Phone:920-380-2715
Mailing Address - Fax:
Practice Address - Street 1:3329 N RICHMOND ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1063
Practice Address - Country:US
Practice Address - Phone:920-380-2715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31401300Medicaid
B84952Medicare UPIN
WI003045300Medicare PIN