Healthcare Provider Details

I. General information

NPI: 1679559975
Provider Name (Legal Business Name): MAX RAY JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 31ST AVE S STE 200
FARGO ND
58104-4556
US

IV. Provider business mailing address

4450 31ST AVE S STE 200
FARGO ND
58104-4556
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-9829
  • Fax: 701-293-0111
Mailing address:
  • Phone: 701-293-9829
  • Fax: 701-293-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number5573
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: