Provider Demographics
NPI:1790876688
Name:JOHNSON, PAUL B (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
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 1:4080 W BROADWAY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5604
Mailing Address - Country:US
Mailing Address - Phone:763-520-5551
Mailing Address - Fax:763-520-1734
Practice Address - Street 1:4080 W BROADWAY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5604
Practice Address - Country:US
Practice Address - Phone:763-520-5551
Practice Address - Fax:763-520-1734
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17347207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB74997Medicare UPIN