Healthcare Provider Details

I. General information

NPI: 1962623280
Provider Name (Legal Business Name): JOHNSON MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N8434 COUNTY RD S
ALGOMA WI
54201-9515
US

IV. Provider business mailing address

N8434 COUNTY RD S
ALGOMA WI
54201-9515
US

V. Phone/Fax

Practice location:
  • Phone: 920-487-5635
  • Fax:
Mailing address:
  • Phone: 920-487-5635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLA A JOHNSON
Title or Position: OWNER AND SOLE PHYSICIAN
Credential: DO
Phone: 920-487-5635