Provider Demographics
NPI:1063418077
Name:JOHNSON, MARK ALAN (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:STE 1845
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2706
Mailing Address - Country:US
Mailing Address - Phone:612-332-8292
Mailing Address - Fax:612-332-5972
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:STE 1845
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2706
Practice Address - Country:US
Practice Address - Phone:612-332-8292
Practice Address - Fax:612-332-5972
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor