1598701906 NPI number — RONALD BRUCE JOHNSON PHD

Table of content: RONALD BRUCE JOHNSON PHD (NPI 1598701906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598701906 NPI number — RONALD BRUCE JOHNSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
RONALD
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598701906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
336 LODI ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LODI
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53555-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-592-2080
Provider Business Mailing Address Fax Number:
608-592-7120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 LODI ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53555-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-592-2080
Provider Business Practice Location Address Fax Number:
608-592-7120
Provider Enumeration Date:
06/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2177-057 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39127800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".