Provider Demographics
NPI:1003801283
Name:JOHNSON, RUSSELL F (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:F
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1215 LAWN AVE STE 120
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2450
Practice Address - Country:US
Practice Address - Phone:574-523-2733
Practice Address - Fax:574-523-3251
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010395332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200001710Medicaid
IN200001710Medicaid
INP01676146OtherRR MEDICARE
IN000000986591OtherANTHEM
E68860Medicare UPIN
IN200001710Medicaid