Provider Demographics
NPI:1164798583
Name:JOHNSON, ARWEN E
Entity Type:Individual
Prefix:
First Name:ARWEN
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 15TH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1888
Mailing Address - Country:US
Mailing Address - Phone:303-532-1536
Mailing Address - Fax:978-291-1875
Practice Address - Street 1:1783 15TH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1888
Practice Address - Country:US
Practice Address - Phone:303-532-1536
Practice Address - Fax:978-291-1875
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0054368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25556215Medicaid