Provider Demographics
NPI:1124093265
Name:JOHNSON, DEBRA DEANOVIC (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:DEANOVIC
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 1:8170 33RD AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-967-7676
Mailing Address - Fax:612-341-1432
Practice Address - Street 1:2220 RIVERSIDE AVE
Practice Address - Street 2:MAIL STOP 31700A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1321
Practice Address - Country:US
Practice Address - Phone:612-371-1600
Practice Address - Fax:612-371-1732
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN310382000Medicaid