1811964117 NPI number — DAVID WENDELL JOHNSON MD

Table of content: DAVID WENDELL JOHNSON MD (NPI 1811964117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811964117 NPI number — DAVID WENDELL JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
DAVID
Provider Middle Name:
WENDELL
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:
1811964117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8170 33RD AVE S # MS 21110Q
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 PHALEN BOULEVARD
Provider Second Line Business Practice Location Address:
MAIL STOP 41102E
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-254-7500
Provider Business Practice Location Address Fax Number:
651-254-7557
Provider Enumeration Date:
03/06/2006

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: 207W00000X , with the licence number:  32520 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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