Healthcare Provider Details

I. General information

NPI: 1417989559
Provider Name (Legal Business Name): GWEN A JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 HUBERTUS RD
HUBERTUS WI
53033
US

IV. Provider business mailing address

3003 W GOOD HOPE RD
MILWAUKEE WI
53209
US

V. Phone/Fax

Practice location:
  • Phone: 262-628-9000
  • Fax: 262-628-7255
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30420
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: