Provider Demographics
NPI:1720030133
Name:JOHNSON, CHAD A (OD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 TUTTLE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913
Mailing Address - Country:US
Mailing Address - Phone:608-356-2020
Mailing Address - Fax:680-356-6787
Practice Address - Street 1:1626 TUTTLE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913
Practice Address - Country:US
Practice Address - Phone:608-356-2020
Practice Address - Fax:680-356-6787
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1875-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720030133Medicaid
WI1720030133Medicaid
WIK400176451Medicare PIN
WI1006716OtherPHYSICIANS PLUS
WI38520100Medicaid
WI410046701Medicare PIN