Provider Demographics
NPI:1235126780
Name:JOHNSON, STEPHEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10700 E GEDDES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3800
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE181662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1235126780Medicaid
SD1235126780/7726960Medicaid
NEP00720335OtherRR MCR NE
NE10025709000Medicaid
NE10025709000Medicaid
NENA1215012Medicare PIN
WY1235126780Medicaid
NENA2517026Medicare PIN
NEE41959Medicare UPIN