Provider Demographics
NPI:1811903057
Name:JOHNSON, MARK BERNARR (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BERNARR
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 1:1801 19TH ST
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-1709
Mailing Address - Country:US
Mailing Address - Phone:303-271-5701
Mailing Address - Fax:303-271-5702
Practice Address - Street 1:1801 19TH ST
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-1709
Practice Address - Country:US
Practice Address - Phone:303-271-5701
Practice Address - Fax:303-271-5702
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO239822083P0901X
CAG576092083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01239821Medicaid