Provider Demographics
NPI:1720013253
Name:JOHNSON, RICHARD E (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MS
Other - First Name:DARLA
Other - Middle Name:J
Other - Last Name:VETSCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MANAGER
Mailing Address - Street 1:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301
Mailing Address - Country:US
Mailing Address - Phone:701-662-5247
Mailing Address - Fax:701-662-4473
Practice Address - Street 1:1031 7TH ST NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301
Practice Address - Country:US
Practice Address - Phone:701-662-5247
Practice Address - Fax:701-662-4473
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND45232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10451Medicaid
D65053Medicare UPIN
ND10451Medicaid