Provider Demographics
NPI:1154365625
Name:JOHNSON, DEVIN BROOKE (MD)
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 STEIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6946
Mailing Address - Country:US
Mailing Address - Phone:715-835-6548
Mailing Address - Fax:715-835-7708
Practice Address - Street 1:3217 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6946
Practice Address - Country:US
Practice Address - Phone:715-835-6548
Practice Address - Fax:715-835-7708
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40161-020208800000X
WI40161-20208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60363OtherDEAN HEALTH INSURANCE
WI34608500Medicaid
WI032113080Medicare PIN
WI036454340Medicare PIN
WI011557085Medicare PIN
K400183744Medicare PIN
WI60363OtherDEAN HEALTH INSURANCE
WIP00187313Medicare PIN
H65502Medicare UPIN