Provider Demographics
NPI:1962842864
Name:JOHNSON, MATTHEW SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
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 1:1301 S CLIFF AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1019
Mailing Address - Country:US
Mailing Address - Phone:605-322-7200
Mailing Address - Fax:
Practice Address - Street 1:1301 S CLIFF AVE STE 700
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1019
Practice Address - Country:US
Practice Address - Phone:605-322-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.133111207ZP0102X
NE6983207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0291746Medicaid