Basic Information
| Provider Information | |||||||||
| NPI: | 1235105388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 NORTHWAY DR | ||||||||
| Address2: | STE 103 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202535220 | ||||||||
| FaxNumber: | 3202032113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 NORTHWAY DR | ||||||||
| Address2: | STE 103 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202275000 | ||||||||
| FaxNumber: | 3202275025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45006 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 45006 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 040993600 | 05 | MN | MEDICAID |