Healthcare Provider Details

I. General information

NPI: 1164428280
Provider Name (Legal Business Name): BENJAMIN H JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 LOBERG AVE
DULUTH MN
55811-2652
US

IV. Provider business mailing address

4190 LOBERG AVE
DULUTH MN
55811-2652
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-5700
  • Fax: 218-249-4666
Mailing address:
  • Phone: 218-249-5700
  • Fax: 218-249-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30419
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39802
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: