Healthcare Provider Details

I. General information

NPI: 1447253968
Provider Name (Legal Business Name): FRANCIS T JOHANSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 PARKWAY DR
BLACKFOOT ID
83221-1667
US

IV. Provider business mailing address

1441 PARKWAY DR
BLACKFOOT ID
83221-1667
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-2600
  • Fax:
Mailing address:
  • Phone: 208-785-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2002023842
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: