Healthcare Provider Details

I. General information

NPI: 1437123361
Provider Name (Legal Business Name): MICHAEL W JOHNSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 MASTHEAD ST NE SUITE 120
ALBUQUERQUE NM
87109-4493
US

IV. Provider business mailing address

PO BOX 36840
ALBUQUERQUE NM
87176-6840
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-7729
  • Fax: 505-243-4804
Mailing address:
  • Phone: 505-243-7729
  • Fax: 505-243-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberS1831
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2001-223
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: