Provider Demographics
NPI:1649281361
Name:JOHNSON, ANDREW J (DPM)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3905
Mailing Address - Country:US
Mailing Address - Phone:218-846-2000
Mailing Address - Fax:218-846-2114
Practice Address - Street 1:1245 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3905
Practice Address - Country:US
Practice Address - Phone:218-846-2000
Practice Address - Fax:218-846-2114
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801213E00000X, 213ES0103X
WAPO00000770213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8436453Medicaid
WAP00235433OtherRAILROAD
WA0207841OtherL & I
WA8905370OtherCRIME VICTIMS
WA0196122OtherL & I
WA8941204OtherCRIME VICTIMS
WAG8852971Medicare PIN
WA0207841OtherL & I
WAP00235433OtherRAILROAD
MN480000671Medicare PIN