Provider Demographics
NPI:1629155692
Name:JOHNSON, DAWN (MD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
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 25100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5100
Mailing Address - Country:US
Mailing Address - Phone:559-326-1222
Mailing Address - Fax:559-421-7004
Practice Address - Street 1:7130 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3347
Practice Address - Country:US
Practice Address - Phone:559-326-1222
Practice Address - Fax:559-421-7004
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40557208600000X
CAC186793208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN010001149Medicaid
MN633819400Medicare ID - Type Unspecified
MN010001149Medicaid