Healthcare Provider Details

I. General information

NPI: 1649454786
Provider Name (Legal Business Name): MR. VICTOR ADEGOKE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 W LYNMAR TER
MILWAUKEE WI
53222-1937
US

IV. Provider business mailing address

8220 W LYNMAR TER
MILWAUKEE WI
53222-1937
US

V. Phone/Fax

Practice location:
  • Phone: 414-460-6734
  • Fax: 414-616-3344
Mailing address:
  • Phone: 414-460-6734
  • Fax: 414-616-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number41451800
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: