Provider Demographics
NPI:1629181706
Name:JOHNSON, JERAY JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JERAY
Middle Name:JAMES
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 1:920 E 1ST ST
Mailing Address - Street 2:P201
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2201
Mailing Address - Country:US
Mailing Address - Phone:218-249-7970
Mailing Address - Fax:218-249-7949
Practice Address - Street 1:920 E 1ST ST
Practice Address - Street 2:P201
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2201
Practice Address - Country:US
Practice Address - Phone:218-249-7970
Practice Address - Fax:218-249-7949
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN44733207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH66039Medicare UPIN