Basic Information
Provider Information | |||||||||
NPI: | 1518982461 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSTONE | ||||||||
FirstName: | CANDICE | ||||||||
MiddleName: | AITKEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AITKEN | ||||||||
OtherFirstName: | CANDICE | ||||||||
OtherMiddleName: | LYNNE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD, MPH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: | DEPARTMENT OF RADIATION ONCOLOGY | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148054400 | ||||||||
FaxNumber: | 4148054369 | ||||||||
Practice Location | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: | DEPARTMENT OF RADIATION ONCOLOGY | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148054400 | ||||||||
FaxNumber: | 4148054369 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 01/31/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | 12688 | NH | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | 55106 | WI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 1011244 | 05 | VT |   | MEDICAID | 1518982461 | 05 | WI |   | MEDICAID | 30205309 | 05 | NH |   | MEDICAID |