Basic Information
| Provider Information | |||||||||
| NPI: | 1811915085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LEIGHTON | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT HEALTH SYSTEM INC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642230 | ||||||||
| FaxNumber: | 6083637394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT HEALTH SYSTEM INC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642230 | ||||||||
| FaxNumber: | 6083637394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/19/2011 | ||||||||
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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 | 207X00000X | 53312-20 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 036068897 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1811915085 | 05 | WI | MEDICAID |