Provider Demographics
NPI:1679559975
Name:JOHNSON, MAX RAY (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:RAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4450 31ST AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4556
Mailing Address - Country:US
Mailing Address - Phone:701-293-9829
Mailing Address - Fax:701-293-0111
Practice Address - Street 1:4450 31ST AVE S STE 200
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4556
Practice Address - Country:US
Practice Address - Phone:701-293-9829
Practice Address - Fax:701-293-0111
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND5573207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0144775OtherCIGNA
ND15935Medicaid
ND3174OtherBLUE CROSS AND BLUE SHIEL
MN109590100Medicaid
180005776OtherRAILROAD MEDICARE
SD7795690Medicaid
MN1M103JOOtherBLUE CROSS AND BLUE SHIEL
01017069OtherPREFERRED ONE
0800999OtherMEDICA
MN1M103JOOtherBLUE CROSS AND BLUE SHIEL