Provider Demographics
NPI:1407856859
Name:JOHNSON, JAN DIANE (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:DIANE
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 1:900 LONG LAKE RD
Mailing Address - Street 2:STE 160
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6414
Mailing Address - Country:US
Mailing Address - Phone:651-631-3759
Mailing Address - Fax:612-706-9617
Practice Address - Street 1:4001 STINSON BLVD
Practice Address - Street 2:STE 404
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3488
Practice Address - Country:US
Practice Address - Phone:612-706-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25663207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110005446Medicare ID - Type Unspecified
A96569Medicare UPIN