Provider Demographics
NPI:1366403743
Name:JOHNSON, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
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 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-773-6600
Mailing Address - Fax:414-773-6656
Practice Address - Street 1:801 S 70TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3147
Practice Address - Country:US
Practice Address - Phone:414-773-6600
Practice Address - Fax:414-773-6656
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32485000Medicaid
WI32485000Medicaid