Provider Demographics
NPI:1073833828
Name:JOHNSON, REBECCA CLARK (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CLARK
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 1:8080 PARK MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-2557
Mailing Address - Country:US
Mailing Address - Phone:720-848-9330
Mailing Address - Fax:
Practice Address - Street 1:9540 PARK MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-2894
Practice Address - Country:US
Practice Address - Phone:720-848-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1550Medicaid