Provider Demographics
NPI:1235105388
Name:JOHNSON, JULIE M (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1511 NORTHWAY DR
Mailing Address - Street 2:STE 103
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1262
Mailing Address - Country:US
Mailing Address - Phone:320-253-5220
Mailing Address - Fax:320-203-2113
Practice Address - Street 1:1511 NORTHWAY DR
Practice Address - Street 2:STE 103
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1262
Practice Address - Country:US
Practice Address - Phone:320-227-5000
Practice Address - Fax:320-227-5025
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN45006207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN040993600Medicaid
F80051Medicare UPIN
F80051Medicare UPIN