Provider Demographics
NPI:1861463648
Name:JOHNSON, STANLEY MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:MARK
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 1:886 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CO
Mailing Address - Zip Code:80118-6534
Mailing Address - Country:US
Mailing Address - Phone:719-488-8868
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39748207Q00000X
KS04-13971207Q00000X
MN20189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20189OtherMEDICAL LICENSE
KSO4-13971OtherMEDICAL LICENSE
CO39748OtherMEDICAL LICENSE
CO39748OtherMEDICAL LICENSE
KSBJ7985293OtherDEA NUMBER
KSBJ7985293OtherDEA NUMBER
COCO307582Medicare PIN