Healthcare Provider Details

I. General information

NPI: 1891182341
Provider Name (Legal Business Name): ROBERT GEORGE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WILLMAR AVE SW
WILLMAR MN
56201-3556
US

IV. Provider business mailing address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5000
  • Fax:
Mailing address:
  • Phone: 208-262-2300
  • Fax: 208-262-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number67607
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-16101
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: