Provider Demographics
NPI:1770524258
Name:JOHNSON, CARMEN LEAH (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LEAH
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 1:315 N OAK BEND DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5223
Mailing Address - Country:US
Mailing Address - Phone:218-729-8883
Mailing Address - Fax:
Practice Address - Street 1:200 BUNKER HILL DR
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1865
Practice Address - Country:US
Practice Address - Phone:218-927-2121
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F71639Medicare UPIN