Provider Demographics
NPI:1629089800
Name:JOHNSON, STEPHANIE JO (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
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 5050
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5050
Mailing Address - Country:US
Mailing Address - Phone:605-322-7200
Mailing Address - Fax:605-322-7222
Practice Address - Street 1:1301 S CLIFF AVE STE 700
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1019
Practice Address - Country:US
Practice Address - Phone:605-322-7200
Practice Address - Fax:605-322-7222
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21154207ZP0102X
IA36940207ZP0102X
SD5966207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807247600Medicaid
30180OtherBCBS
9173120OtherDAKOTACARE
MN642398100Medicaid
SD7706280Medicaid
AZ896110OtherARIZONA HEALTH CARE COST
WY114658100Medicaid
220026517OtherRAILROAD MEDICARE
WY114658100Medicaid
220026517OtherRAILROAD MEDICARE