Provider Demographics
NPI:1184741837
Name:DOUG JOHNSON MD PC
Entity type:Organization
Organization Name:DOUG JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:719-395-8632
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-3129
Mailing Address - Country:US
Mailing Address - Phone:719-395-8632
Mailing Address - Fax:719-395-4971
Practice Address - Street 1:36 OAK STREET
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211
Practice Address - Country:US
Practice Address - Phone:719-395-8632
Practice Address - Fax:719-395-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35510207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04016812Medicaid
CO04016812Medicaid