Provider Demographics
NPI:1649381997
Name:JOHNSON, CHARLES BISSELL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BISSELL
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 1:8402 CLAY STREET
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-3846
Mailing Address - Country:US
Mailing Address - Phone:303-426-0928
Mailing Address - Fax:303-426-9771
Practice Address - Street 1:8402 CLAY STREET
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3846
Practice Address - Country:US
Practice Address - Phone:303-426-0928
Practice Address - Fax:303-426-9771
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01186519Medicaid
CO01186519Medicaid
COC46491Medicare PIN