Basic Information
| Provider Information | |||||||||
| NPI: | 1821080391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DARLENE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | DARLENE | ||||||||
| OtherMiddleName: | KARIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1390 S POTOMAC ST | ||||||||
| Address2: | SUITE 124 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800126165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033688611 | ||||||||
| FaxNumber: | 3033689791 | ||||||||
| Practice Location | |||||||||
| Address1: | 1390 S POTOMAC ST | ||||||||
| Address2: | SUITE 124 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800126165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033688611 | ||||||||
| FaxNumber: | 3033689791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 41812 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 41812 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00176398 | 01 | CO | RR MEDICARE | OTHER | 68136366 | 05 | CO | MEDICAID |