Provider Demographics
NPI:1821183211
Name:JOHNSON, TRYSTAIN D (MD)
Entity Type:Individual
Prefix:
First Name:TRYSTAIN
Middle Name:D
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 1:938 BANNOCK ST
Mailing Address - Street 2:STE 300
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204
Mailing Address - Country:US
Mailing Address - Phone:303-914-8800
Mailing Address - Fax:303-716-3777
Practice Address - Street 1:938 BANNOCK ST
Practice Address - Street 2:STE 300
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:303-716-3777
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO415292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49537563Medicaid
COC801369Medicare PIN
COC809549Medicare PIN
COI09098Medicare UPIN
CO49537563Medicaid
COC801370Medicare PIN
COP00250508Medicare PIN
COC802272Medicare PIN
COC803975Medicare PIN
COC807704Medicare PIN