Healthcare Provider Details

I. General information

NPI: 1255863510
Provider Name (Legal Business Name): TERESA MARIA JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BLAKE AVE
GLENWOOD SPRINGS CO
81601-4259
US

IV. Provider business mailing address

1906 BLAKE AVE
GLENWOOD SPRINGS CO
81601-4259
US

V. Phone/Fax

Practice location:
  • Phone: 970-384-7340
  • Fax: 970-928-2530
Mailing address:
  • Phone: 970-384-7033
  • Fax: 970-384-8174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR.0063952
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: