Healthcare Provider Details

I. General information

NPI: 1962555847
Provider Name (Legal Business Name): GARY N JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E BROADWAY AVE
BISMARCK ND
58501-4520
US

IV. Provider business mailing address

PO BOX 997
BISMARCK ND
58502-0997
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-6500
  • Fax:
Mailing address:
  • Phone: 701-530-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number4094
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4094
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number4094
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: