Provider Demographics
NPI:1750300430
Name:JOHNSON, GARY LEE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
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 1:1265 JOHN Q HAMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1941
Mailing Address - Country:US
Mailing Address - Phone:608-251-4156
Mailing Address - Fax:608-257-3842
Practice Address - Street 1:1265 JOHN Q HAMMONS DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1941
Practice Address - Country:US
Practice Address - Phone:608-251-4156
Practice Address - Fax:608-257-3842
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine