Healthcare Provider Details

I. General information

NPI: 1619902012
Provider Name (Legal Business Name): JON J JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HERITAGE WAY STE 2100
KALISPELL MT
59901
US

IV. Provider business mailing address

350 HERITAGE WAY STE 2100
KALISPELL MT
59901
US

V. Phone/Fax

Practice location:
  • Phone: 406-257-8992
  • Fax: 406-257-8996
Mailing address:
  • Phone: 406-257-8992
  • Fax: 406-257-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number7910
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: