Provider Demographics
NPI:1376688150
Name:JOHNSON, MATTHEW ROBERT (MD, MPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 N SIOUX POINT RD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5312
Mailing Address - Country:US
Mailing Address - Phone:605-217-2667
Mailing Address - Fax:605-217-2900
Practice Address - Street 1:575 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-217-2667
Practice Address - Fax:605-217-2900
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37278207T00000X
NE4526207T00000X
SD7024207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI20751Medicare PIN
SD103427Medicare PIN
SD1295480001Medicare NSC
IA1295480002Medicare NSC