Provider Demographics
NPI:1730282518
Name:JOHNSON, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
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 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:333 SMITH AVE N STE 4640
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-241-1001
Practice Address - Fax:651-241-1116
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26128207Q00000X
MN45750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR840292006OtherREGENCE
911019392OtherCOMMERCIAL
911019392OtherCOMMERCIAL
I01044Medicare UPIN