Provider Demographics
NPI:1912918772
Name:JOHNSON, ANTHONY T (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:T
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 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:102 MANDAN AVE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3771
Practice Address - Country:US
Practice Address - Phone:701-667-5000
Practice Address - Fax:701-323-5709
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18610Medicaid
ND14761Medicare PIN
ND18610Medicaid