Healthcare Provider Details

I. General information

NPI: 1831728807
Provider Name (Legal Business Name): SAMANTHA R JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA VAN GHEEM

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 S WEBSTER AVE
GREEN BAY WI
54301-2253
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351046547
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82224-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: