Provider Demographics
NPI:1912063652
Name:JOHNSON, CARL AUSTIN (MPT)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:AUSTIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 LINDEE LANE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-523-4815
Mailing Address - Fax:
Practice Address - Street 1:285 W FRANCIS
Practice Address - Street 2:BLACKFOOT PHYSICAL THERAPY
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-0123
Practice Address - Fax:208-782-1885
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT4629OtherBLUE CROSS
ID136533Medicare ID - Type Unspecified