Provider Demographics
NPI:1558330134
Name:JOHNSON, RODGER L (MD)
Entity Type:Individual
Prefix:
First Name:RODGER
Middle Name:L
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 1:1580 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1127
Mailing Address - Country:US
Mailing Address - Phone:651-779-7978
Mailing Address - Fax:651-779-7656
Practice Address - Street 1:1580 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1127
Practice Address - Country:US
Practice Address - Phone:651-779-7978
Practice Address - Fax:651-779-7656
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18580207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN23257OtherAMERICA'S PPO
MN3600784OtherMEDICA
MN105481OtherUCARE MN
WI61275900Medicaid
MNHP13626OtherHEALTHPARTNERS
MN0010102OtherPREFERREDONE
MN8T422JOOtherBLUE CROSS BLUE SHIELD MN
MN8T422JOOtherBLUE CROSS BLUE SHIELD MN