Provider Demographics
NPI:1366494809
Name:JOHNSON, PHILIP QUENTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:QUENTIN
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 1:2829 UNIVERSITY DR S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6050
Mailing Address - Country:US
Mailing Address - Phone:701-478-0307
Mailing Address - Fax:701-478-0309
Practice Address - Street 1:2829 UNIVERSITY DR S
Practice Address - Street 2:SUITE 202
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6050
Practice Address - Country:US
Practice Address - Phone:701-478-0307
Practice Address - Fax:701-478-0309
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6195207X00000X, 207XX0005X
MN34857207X00000X, 207XX0005X
AZ25154207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16785Medicaid
ND16785Medicaid
NDN11025Medicare PIN