Provider Demographics
NPI:1285642322
Name:JOHNSON, TERESA KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 E 17TH STREET
Mailing Address - Street 2:IDAHO FALLS
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-529-2544
Mailing Address - Fax:208-529-3771
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:IDAHO FALLS
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-529-2544
Practice Address - Fax:208-529-3771
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806599100Medicaid
ID806599100Medicaid
ID1110964Medicare ID - Type Unspecified