Provider Demographics
NPI:1225189533
Name:JOHNSON, MARK ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:MN
Mailing Address - Zip Code:55369-1122
Mailing Address - Country:US
Mailing Address - Phone:763-425-2347
Mailing Address - Fax:
Practice Address - Street 1:2780 SNELLING AVE N
Practice Address - Street 2:SUITE 301
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-7115
Practice Address - Country:US
Practice Address - Phone:651-633-9667
Practice Address - Fax:651-633-4203
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39732Medicare UPIN