Provider Demographics
NPI:1336156132
Name:JOHNSON, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
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 1:2809 E HAMILTON AVE # 107
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6863
Mailing Address - Country:US
Mailing Address - Phone:715-834-1555
Mailing Address - Fax:715-835-0263
Practice Address - Street 1:2809 E HAMILTON AVE # 107
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6863
Practice Address - Country:US
Practice Address - Phone:715-834-1555
Practice Address - Fax:715-835-0263
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00468921OtherMEDICARE RAILROAD
WI010000495Medicare PIN
WIK400121786Medicare PIN
WIP00468921OtherMEDICARE RAILROAD