Provider Demographics
NPI:1457419988
Name:JOHNSON, GARY A (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
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 1:1024 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-1236
Mailing Address - Country:US
Mailing Address - Phone:715-234-8151
Mailing Address - Fax:
Practice Address - Street 1:1024 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1236
Practice Address - Country:US
Practice Address - Phone:715-234-8151
Practice Address - Fax:715-234-9750
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224112085R0202X
MN462142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN230014100Medicaid
WI31559000Medicaid
WI31559000Medicaid
WI05055-0001Medicare ID - Type Unspecified
MN230014100Medicaid