Provider Demographics
NPI:1821177346
Name:JOHNSON, MIKE A (MD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:A
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 1:500 15TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4324
Mailing Address - Country:US
Mailing Address - Phone:406-455-2680
Mailing Address - Fax:406-455-2685
Practice Address - Street 1:500 15TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4324
Practice Address - Country:US
Practice Address - Phone:406-455-2680
Practice Address - Fax:406-455-2685
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0115906Medicaid
MT000092806OtherBLUE CROSS BLUE SHIELD
MT000085237Medicare ID - Type Unspecified
MTP00295394Medicare ID - Type UnspecifiedMEDICARE RAILROAD
MT0115906Medicaid