Provider Demographics
NPI:1659857654
Name:JOHNSON, ABIMBOLA (DPM)
Entity Type:Individual
Prefix:DR
First Name:ABIMBOLA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 6TH ST E APT 324
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN257213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery