Provider Demographics
NPI:1871595850
Name:JOHNSON, MICHAEL B (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
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 1:2211 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3711
Mailing Address - Country:US
Mailing Address - Phone:612-871-1144
Mailing Address - Fax:612-871-2012
Practice Address - Street 1:347 SMITH AVE N
Practice Address - Street 2:SUITE 602
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2387
Practice Address - Country:US
Practice Address - Phone:651-227-0821
Practice Address - Fax:651-297-6597
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43178207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1025272OtherPREFERREDONE
WI34011200OtherMEDICAID - WISCONSIN
MN91D32J0OtherBLUE SHIELD
MN140142OtherUCARE
MN335402400Medicaid
MN1102768OtherAMERICA'S PPO
MN1000010OtherMEDICA PRIMARY
MN1000215OtherMEDICA CHOICE
MN1025272OtherPREFERREDONE
MN040000574Medicare PIN