Provider Demographics
NPI:1891797171
Name:JOHNSON, RICHARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
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 1:1006 ROBERTSON ST
Mailing Address - Street 2:STE 104
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3948
Mailing Address - Country:US
Mailing Address - Phone:970-484-9027
Mailing Address - Fax:970-484-2283
Practice Address - Street 1:1006 ROBERTSON ST
Practice Address - Street 2:STE 104
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3948
Practice Address - Country:US
Practice Address - Phone:970-484-9027
Practice Address - Fax:970-484-2283
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19654207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01196542Medicaid
COC46951Medicare ID - Type Unspecified
CO01196542Medicaid