Provider Demographics
NPI:1245595081
Name:JOHNSON, ROBERT ALLEN (DO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALLEN
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 1:100 MAC LANE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5285
Mailing Address - Fax:605-945-5295
Practice Address - Street 1:521 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3142
Practice Address - Country:US
Practice Address - Phone:605-945-5560
Practice Address - Fax:605-224-0369
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9542207Q00000X
390200000X
SD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine