Provider Demographics
NPI:1467504597
Name:JOHNSON, CHERYL K (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
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:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-0260
Mailing Address - Country:US
Mailing Address - Phone:319-626-6006
Mailing Address - Fax:319-626-3400
Practice Address - Street 1:585 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9797
Practice Address - Country:US
Practice Address - Phone:319-626-6006
Practice Address - Fax:319-626-3400
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA251280OtherWELLMARK
IA1024398Medicaid
IA1024398Medicaid
IAA03424Medicare UPIN