Provider Demographics
NPI:1205885852
Name:JOHNSON, CLARENNCE E (MD)
Entity type:Individual
Prefix:
First Name:CLARENNCE
Middle Name:E
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 1:700 S PARK ST
Mailing Address - Street 2:ST MARYS HOSPITAL/DEAN MEDICAL CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1849
Mailing Address - Country:US
Mailing Address - Phone:608-258-6975
Mailing Address - Fax:608-258-5222
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:ST MARYS HOSPITAL/DEAN MEDICAL CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1849
Practice Address - Country:US
Practice Address - Phone:608-258-6975
Practice Address - Fax:608-258-5222
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25837-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4383OtherDEAN HEALTH INSURANCE
WI31560700Medicaid
WI075274150Medicare PIN
WI4383OtherDEAN HEALTH INSURANCE
WI050086460Medicare PIN