Healthcare Provider Details

I. General information

NPI: 1033188347
Provider Name (Legal Business Name): JUDITH L JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 1ST ST SUITE LL
DULUTH MN
55805-2297
US

IV. Provider business mailing address

1000 E 1ST ST SUITE LL
DULUTH MN
55805-2297
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-5629
  • Fax: 218-722-5148
Mailing address:
  • Phone: 218-722-5629
  • Fax: 218-722-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number40719
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: