Healthcare Provider Details

I. General information

NPI: 1407976012
Provider Name (Legal Business Name): MR. JOHNNY WALKER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. JOHNNY WALKER JR.

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4523 W MEDFORD AVE
MILWAUKEE WI
53216-3448
US

IV. Provider business mailing address

4523 W MEDFORD AVE
MILWAUKEE WI
53216-3448
US

V. Phone/Fax

Practice location:
  • Phone: 414-445-3373
  • Fax: 414-873-3299
Mailing address:
  • Phone: 414-445-3373
  • Fax: 414-873-9296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberW4264205140705
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: