Provider Demographics
NPI:1649454786
Name:JOHNSON, VICTOR ADEGOKE
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:ADEGOKE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 W LYNMAR TER
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1937
Mailing Address - Country:US
Mailing Address - Phone:414-460-6734
Mailing Address - Fax:414-616-3344
Practice Address - Street 1:8220 W LYNMAR TER
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1937
Practice Address - Country:US
Practice Address - Phone:414-460-6734
Practice Address - Fax:414-616-3344
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41451800343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41451800Medicaid