Healthcare Provider Details

I. General information

NPI: 1508975145
Provider Name (Legal Business Name): RICK JOHNSON, D.O., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/16/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 WILDWOOD LN
MANHATTAN KS
66502-3610
US

IV. Provider business mailing address

2317 WILDWOOD LN
MANHATTAN KS
66502-3610
US

V. Phone/Fax

Practice location:
  • Phone: 785-473-6848
  • Fax: 785-263-3979
Mailing address:
  • Phone: 785-473-6848
  • Fax: 785-263-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number05-21868
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100235990A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer
# 2
Identifier040648
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerBLUECROSS/BLUE SHIELD

VIII. Authorized Official

Name: RICK JOHNSON
Title or Position: OWNER
Credential: DO
Phone: 785-473-7060