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General NPI Number Information
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NPI Number | 1811964174
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Entity Type | Individual
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Provider Name | BLAKE A JOHNSON MD
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Gender | Male
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Dates
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Enumeration Date | 03/07/2006
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Last Update Date | 02/17/2012
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Provider Practice Location Address
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Address Line | 5775 WAYZATA BLVD STE 190
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City | ST LOUIS PARK
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State | MN
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Zip | 55416
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Country | US
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Telephone | 952-541-1840
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Fax | 952-513-6880
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Provider Business Mailing Address
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Address Line | PO BOX 1450 NW6035
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City | MINNEAPOLIS
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State | MN
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Zip | 55485-6035
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Country | US
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Telephone | 952-542-8553
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Fax | 952-513-6880
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 39490
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License Number State | MN
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