Provider Demographics
NPI:1679535991
Name:JOHNSON, CAROL J (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
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 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:651-245-1130
Mailing Address - Fax:
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45735207Q00000X
MN45749207QG0300X
ND15917207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP38799OtherHEALTH PARTNERS
MNP00047499OtherRAILROAD MEDICARE
MN66-06190OtherMEDICA URGENT CARE
MN072K4J0OtherBLUE CROSS
MN171680OtherUCARE MINNESOTA
MN1882619OtherAMERICA'S PPO
MN2110090OtherFIRST HEALTH GROUP
WI34407600Medicaid
MN607632700OtherGROUP HEALTH EAU CLAIRE
MNNA9141035345OtherPREFERRED ONE
MN01-18712OtherMEDICA
MN607632700Medicaid
MNH88569Medicare UPIN
MN2110090OtherFIRST HEALTH GROUP