Provider Demographics
NPI:1588660393
Name:JOHNSON, PETER DAVID (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:DAVID
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9556
Mailing Address - Fax:605-328-9501
Practice Address - Street 1:1210 W 18TH ST
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-9890
Practice Address - Country:US
Practice Address - Phone:605-312-8500
Practice Address - Fax:605-312-8501
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4108208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6100182Medicaid
F85479Medicare UPIN
SDS42247Medicare PIN
SD6100182Medicaid