MEDICARE: DR. SAMUEL STUART JOHNSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	6454773-1205	UT
2	207Q00000X	Family Medicine Physician	12967	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043212749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL STUART JOHNSON M.D.

Provider Business Mailing Address
First Line	:	315 MAIN ST # 676
Second Line	:
City	:	NEW TOWN
State	:	ND
Zip	:	58763-4000
Country	:	US
Telephone Number	:	385-414-1376
Fax Number	:	888-877-8471

Provider Business Practice Location Address
First Line	:	1058 COLLEGE DR
Second Line	:
City	:	NEW TOWN
State	:	ND
Zip	:	58763-9112
Country	:	US
Telephone Number	:	701-627-4750
Fax Number	:	888-877-8471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	05/08/2015

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