Provider Demographics
NPI:1265515977
Name:JOHNSON, BARRY DUANE (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:DUANE
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1100 S CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-5518
Practice Address - Country:US
Practice Address - Phone:906-776-5480
Practice Address - Fax:906-228-0203
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042058204D00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1302200421OtherBCBS MI
MI3463356 10Medicaid
WI30305300Medicaid
MIP00626141OtherRR MEDICARE
MI3463356 10Medicaid
WI30305300Medicaid
MIP00626141OtherRR MEDICARE