Healthcare Provider Details

I. General information

NPI: 1225039118
Provider Name (Legal Business Name): DOUGLAS EDWARD JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W KANSAS AVE
ULYSSES KS
67880-2034
US

IV. Provider business mailing address

202 W KANSAS AVE
ULYSSES KS
67880-2034
US

V. Phone/Fax

Practice location:
  • Phone: 620-356-5870
  • Fax: 620-356-5867
Mailing address:
  • Phone: 620-356-5870
  • Fax: 620-356-5867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-27920
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0527920
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: