Provider Demographics
NPI:1902810716
Name:JOHNSON, BETH G (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 A AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5057
Mailing Address - Country:US
Mailing Address - Phone:319-362-0200
Mailing Address - Fax:319-399-5186
Practice Address - Street 1:855 A AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5057
Practice Address - Country:US
Practice Address - Phone:319-362-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1902810716Medicaid
IAP00360616OtherRR MEDICARE
IAI18422Medicare PIN
IA1902810716Medicaid