Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 25307 | WI |
NPI | 1659339919 |
---|---|
Provider Name | Dr. Tad Mark Johnson |
First Address | Janesville, WI 53546-1626 |
Second Address | Janesville, WI 53546-1626 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 06/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1659339919 | (05) | WI |
1659339919 | BCBSWI (01) | WI |
30661900 | (05) | WI |
B53913 | (02) | WI |
JOHNSTAD | MERCYCARE INSURANCE (01) | WI |