Provider Demographics
NPI:1235189143
Name:JOHNSON, DALE S (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
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 1:1319 VIVIAN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3216
Mailing Address - Country:US
Mailing Address - Phone:303-772-3611
Mailing Address - Fax:303-772-3609
Practice Address - Street 1:1319 VIVIAN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3216
Practice Address - Country:US
Practice Address - Phone:303-772-3611
Practice Address - Fax:303-772-3609
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18358207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01183581Medicaid
D23424Medicare UPIN
CO01183581Medicaid