Provider Demographics
NPI:1932104098
Name:JOHNSON, TERESA K (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7001
Mailing Address - Country:US
Mailing Address - Phone:907-235-8586
Mailing Address - Fax:907-235-6639
Practice Address - Street 1:4136 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7001
Practice Address - Country:US
Practice Address - Phone:907-235-8586
Practice Address - Fax:907-235-6639
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS21456207Q00000X
AKMEDS8281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSE06604Medicare UPIN
KSE06604Medicare UPIN
KS101421Medicare ID - Type Unspecified