Provider Demographics
NPI:1043212749
Name:JOHNSON, SAMUEL STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:STUART
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 1:315 MAIN ST # 676
Mailing Address - Street 2:
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763-4000
Mailing Address - Country:US
Mailing Address - Phone:385-414-1376
Mailing Address - Fax:888-877-8471
Practice Address - Street 1:1058 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763-9112
Practice Address - Country:US
Practice Address - Phone:701-627-4750
Practice Address - Fax:888-877-8471
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6454773-1205207Q00000X
NV12967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003763400Medicaid
ID003763400Medicaid
ID003763400Medicaid