Healthcare Provider Details

I. General information

NPI: 1730148560
Provider Name (Legal Business Name): THOMAS HAGGE JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAINT JOHNS BLVD STE 200
MAPLEWOOD MN
55109-1190
US

IV. Provider business mailing address

1600 SAINT JOHNS BLVD STE 200
MAPLEWOOD MN
55109-1190
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-4327
  • Fax: 651-326-8171
Mailing address:
  • Phone: 651-236-4327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number31296
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: