1124043468 NPI number — WALTER S JOHNSON MD

Table of content: WALTER S JOHNSON MD (NPI 1124043468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124043468 NPI number — WALTER S JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
WALTER
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124043468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58108-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-364-3300
Provider Business Mailing Address Fax Number:
701-364-8906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1702 UNIVERSITY DR S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-4940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-364-3300
Provider Business Practice Location Address Fax Number:
701-364-8906
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4262 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152020 . This is a "UCARE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 80950JO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 910828 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 15638 . This is a "SIOUX VALLEY #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 0404050 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: ND100004 . This is a "LHS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 30224JO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 15078 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 79896JO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 0402561 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 2120 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 625005000 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 79897JO . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DA9011015546 . This is a "PREFERRED ONE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: HP19546 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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