Provider Demographics
NPI:1609997121
Name:JOHNSON, NATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
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 1:5800 FOXRIDGE DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2347
Mailing Address - Country:US
Mailing Address - Phone:913-261-3153
Mailing Address - Fax:
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-355842085R0202X
MO20120091532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200877220AMedicaid
KSP01094625OtherRR MEDICARE
MOP01119931OtherRR MEDICARE
KS200877220BMedicaid
KSP01115725OtherRR MEDICARE
MOJ9600017Medicare PIN
KS200877220BMedicaid
KSJ96A00013Medicare PIN
MOP01119931OtherRR MEDICARE
MOJ96B00039Medicare PIN