Provider Demographics
NPI:1609812718
Name:JOHANNSEN, MARK CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTIAN
Last Name:JOHANNSEN
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 1:415 EAST 23RD ST
Mailing Address - Street 2:STE 210
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2343
Mailing Address - Country:US
Mailing Address - Phone:402-721-4866
Mailing Address - Fax:402-721-3229
Practice Address - Street 1:450 E 23RD ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025
Practice Address - Country:US
Practice Address - Phone:402-721-3070
Practice Address - Fax:402-727-3513
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE194062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47058135000Medicaid
088338Medicare ID - Type Unspecified
E29169Medicare UPIN