MEDICARE: DR. CHARLES LARUE JOHNSON D.O.

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	18812	CO

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	:	1760447767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES LARUE JOHNSON D.O.

Provider Business Mailing Address
First Line	:	155 PRINTERS PKWY
Second Line	:	SUITE 230
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-6100
Country	:	US
Telephone Number	:	719-635-5657
Fax Number	:	719-578-9014

Provider Business Practice Location Address
First Line	:	155 PRINTERS PKWY
Second Line	:	SUITE 230
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-6100
Country	:	US
Telephone Number	:	719-635-5657
Fax Number	:	719-578-9014

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	03/01/2010

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