Provider Demographics
NPI:1225039118
Name:JOHNSON, DOUGLAS EDWARD (DO)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2034
Mailing Address - Country:US
Mailing Address - Phone:620-356-5870
Mailing Address - Fax:620-356-5867
Practice Address - Street 1:202 W KANSAS AVE
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2034
Practice Address - Country:US
Practice Address - Phone:620-356-5870
Practice Address - Fax:620-356-5867
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-27920207Q00000X
KS0527920207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1316916638OtherNPI NUMBER
KS100321440CMedicaid
KS1316916638OtherNPI NUMBER
KS110812Medicare ID - Type Unspecified