Provider Demographics
NPI:1821038944
Name:JOHNSON, DAVE R (MD)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:R
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 1:101 E MINNESOTA ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7756
Mailing Address - Country:US
Mailing Address - Phone:605-718-7450
Mailing Address - Fax:605-718-7465
Practice Address - Street 1:101 E MINNESOTA ST
Practice Address - Street 2:SUITE 260
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7756
Practice Address - Country:US
Practice Address - Phone:605-718-7450
Practice Address - Fax:605-718-7465
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD1584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6001252Medicaid
SD6001252Medicaid
SDS40193Medicare PIN