Provider Demographics
NPI:1801038476
Name:JOHNSON, DANIEL R (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:723 PARK RIDGE LANE
Practice Address - Street 2:
Practice Address - City:N FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1385
Practice Address - Country:US
Practice Address - Phone:920-926-8600
Practice Address - Fax:920-926-8650
Is Sole Proprietor?:No
Enumeration Date:2009-03-29
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54734-21207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01116811OtherRAILROAD MEDICARE
WI1801038476Medicaid
WI1801038476Medicaid