Provider Demographics
NPI:1659453892
Name:JOHNSON, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
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:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-3129
Mailing Address - Country:US
Mailing Address - Phone:719-395-5869
Mailing Address - Fax:
Practice Address - Street 1:36 OAK STREET
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211-3129
Practice Address - Country:US
Practice Address - Phone:719-395-8632
Practice Address - Fax:719-395-4971
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33922207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01339225Medicaid
CO01339225Medicaid
A01301Medicare UPIN