Provider Demographics
NPI:1760472336
Name:JOHNSON, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
600904OtherARAZ GROUP AMERICAS PPO
108498OtherUCARE
110104495OtherRR MEDICARE
2114099OtherFIRST HEALTH PLAN
6D070JOOtherBLUE CROSS BLUE SHIELD
986013OtherPREFERRED ONE
0426968OtherMEDICA HEALTH PLANS
HP22733OtherHEALTH PARTNERS
899297500OtherMEDICAL ASSISTANCE
899297500OtherMEDICAL ASSISTANCE
E57116Medicare UPIN
119001620Medicare ID - Type Unspecified