Provider Demographics
NPI:1184751349
Name:JOHNSON, CRAIG JOEL (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:JOEL
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:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53191-0358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 ELKHORN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMS BAY
Practice Address - State:WI
Practice Address - Zip Code:53191-9514
Practice Address - Country:US
Practice Address - Phone:262-245-2600
Practice Address - Fax:262-245-6600
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI290922084N0400X
IL2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31398400Medicaid
WI31398400Medicaid