Provider Demographics
NPI:1033188347
Name:JOHNSON, JUDITH L (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 1ST ST
Mailing Address - Street 2:SUITE LL
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-722-5629
Mailing Address - Fax:218-722-5148
Practice Address - Street 1:1000 E 1ST ST
Practice Address - Street 2:SUITE LL
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-722-5629
Practice Address - Fax:218-722-5148
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40719174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01017175OtherPREFERRED ONE
MN31B35JOOtherBLUE CROSS BLUE SHIELD
A011OtherTRICARE
MN199824200Medicaid
MN123030OtherUCARE
WI32459800Medicaid
MNHP26562OtherHEALTH PARTNERS
MN0708040OtherMEDICA
A011OtherTRICARE
MN31B35JOOtherBLUE CROSS BLUE SHIELD