Healthcare Provider Details

I. General information

NPI: 1962729111
Provider Name (Legal Business Name): ANDREW DAVID JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE MMC 609
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

420 DELAWARE ST SE MMC 609
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-2686
  • Fax: 612-625-1121
Mailing address:
  • Phone: 612-626-2686
  • Fax: 612-625-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number57246
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: