Provider Demographics
NPI:1124043468
Name:JOHNSON, WALTER S (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:S
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4262207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND152020OtherUCARE #
ND80950JOOtherMNBS #
ND910828OtherAMERICA'S PPO/ARAZ #
ND15638OtherSIOUX VALLEY #
ND0404050OtherMEDICA #
NDND100004OtherLHS #
ND30224JOOtherMNBS #
ND15078Medicaid
ND79896JOOtherMNBS #
ND0402561OtherMEDICA #
ND2120OtherNDBS #
ND625005000Medicaid
MN79897JOOtherMNBS #
NDDA9011015546OtherPREFERRED ONE #
NDHP19546OtherHEALTHPARTNERS #
NDHP19546OtherHEALTHPARTNERS #
ND2269Medicare ID - Type UnspecifiedND MEDICARE #
ND0404050OtherMEDICA #
NDDA9011015546OtherPREFERRED ONE #
ND80950JOOtherMNBS #