Provider Demographics
NPI:1215941638
Name:KURT S. JOHNSON, MD, PC
Entity type:Organization
Organization Name:KURT S. JOHNSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-742-3242
Mailing Address - Street 1:3236 E GRAND AVE STE G
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5100
Mailing Address - Country:US
Mailing Address - Phone:307-742-3242
Mailing Address - Fax:307-742-3282
Practice Address - Street 1:3236 E GRAND AVE STE G
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5100
Practice Address - Country:US
Practice Address - Phone:307-742-3242
Practice Address - Fax:307-742-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6832A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9605Medicare ID - Type Unspecified