Provider Demographics
NPI:1053639732
Name:JOHNSON, MELANIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3300
Mailing Address - Country:US
Mailing Address - Phone:651-426-3995
Mailing Address - Fax:651-426-5626
Practice Address - Street 1:4653 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-426-3995
Practice Address - Fax:651-426-5626
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN939213ES0131X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery