Basic Information
| Provider Information | |||||||||
| NPI: | 1205857901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 573 MONTEREY TRL | ||||||||
| Address2: | |||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570495284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054221130 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 TOWER RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570495007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052177246 | ||||||||
| FaxNumber: | 6052174878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 4163 | SD | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1141994 | 05 | IA | MEDICAID | 5701170 | 05 | SD | MEDICAID |