Basic Information
| Provider Information | |||||||||
| NPI: | 1720030133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 TUTTLE ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083562020 | ||||||||
| FaxNumber: | 6803566787 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 TUTTLE ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083562020 | ||||||||
| FaxNumber: | 6803566787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 01/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1875-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1720030133 | 05 | WI | MEDICAID |