Provider Demographics
NPI:1558550178
Name:JOHNSON, ROBERT SIDNEY (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SIDNEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 BEMIDJI AVE N
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4333
Mailing Address - Country:US
Mailing Address - Phone:218-751-5145
Mailing Address - Fax:218-444-2480
Practice Address - Street 1:3620 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4333
Practice Address - Country:US
Practice Address - Phone:218-751-5145
Practice Address - Fax:218-444-2480
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN001724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN17453OtherBLUE CROSS BLUE SHEILD ND
MN82386JOOtherBLUE CROSS BLUE SHEILD MN
MN82386JOOtherBLUE CROSS BLUE SHEILD MN
MNC04034Medicare PIN