Provider Demographics
NPI:1669481057
Name:JOHNSON, RORY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:RORY
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2345 CANTERBURY LN
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234-5602
Practice Address - Country:US
Practice Address - Phone:920-868-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33328200Medicaid
H18503Medicare UPIN