Provider Demographics
NPI:1952389306
Name:JOHNSON, DAVID EMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EMANUEL
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 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-983-4300
Mailing Address - Fax:218-983-6307
Practice Address - Street 1:40520 COUNTY HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9612
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6307
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0358207R00000X
NM20040358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT6588Medicaid
48626Medicare UPIN
NMT6588Medicaid