Healthcare Provider Details

I. General information

NPI: 1326134875
Provider Name (Legal Business Name): STEPHEN MACKEMER JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: STEPHEN JOHNSON MD

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 THREE SPRINGS BLVD
DURANGO CO
81301
US

IV. Provider business mailing address

PO BOX 17752
DENVER CO
80217-0752
US

V. Phone/Fax

Practice location:
  • Phone: 303-306-7783
  • Fax: 303-306-7753
Mailing address:
  • Phone: 303-306-7783
  • Fax: 303-306-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR0025637
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR0025637
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: