Provider Demographics
NPI:1013958537
Name:JOHNSON, MARISE K (MD)
Entity type:Individual
Prefix:
First Name:MARISE
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 1:1280 BURNS WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3110
Mailing Address - Country:US
Mailing Address - Phone:406-755-5266
Mailing Address - Fax:406-755-0228
Practice Address - Street 1:1280 BURNS WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3110
Practice Address - Country:US
Practice Address - Phone:406-755-5266
Practice Address - Fax:406-755-0228
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4632207R00000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0011687Medicaid
MT000025223Medicare ID - Type UnspecifiedMEDICARE
MTD07956Medicare UPIN