Basic Information
| Provider Information | |||||||||
| NPI: | 1679581227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8055 O ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685102580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024210896 | ||||||||
| FaxNumber: | 4024210945 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 S 40TH ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685062407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836000 | ||||||||
| FaxNumber: | 4024836106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16056 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35833 | 01 | NE | BCBS | OTHER | 01-00145 | 01 | NE | UHC | OTHER | 1208 | 01 | NE | MIDLAND'S CHOICE | OTHER | 470780857 32 | 05 | NE | MEDICAID |