Provider Demographics
NPI:1568454502
Name:JOHNSON, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN33783207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP25456OtherHEALTH PARTNERS
6D71JOOtherBLUE CROSS BLUE SHIELD
686002800OtherMEDICAL ASSISTANCE
986014OtherPREFERRED ONE
MN686002800Medicaid
110104487OtherRR MEDICARE
110904OtherU CARE
2529937OtherMEDICA HEALTH PLANS
600885OtherARAZ GROUP AMERICAS PPO
2114001OtherFIRST HEALTH PLAN
686002800OtherMEDICAL ASSISTANCE
069000175Medicare PIN