Provider Demographics
NPI:1316960032
Name:JOHNSON, KIMBERLY DALE (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DALE
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:PO BOX 4002
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-4002
Mailing Address - Country:US
Mailing Address - Phone:970-884-0548
Mailing Address - Fax:
Practice Address - Street 1:4820 EAST MAIN STREET
Practice Address - Street 2:SJRMC URGENT CARE
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402
Practice Address - Country:US
Practice Address - Phone:505-609-6495
Practice Address - Fax:505-609-6496
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32573207P00000X
NMMD2009-0511207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK5584Medicaid
CO01325737Medicaid
CO01325737Medicaid
COC804594Medicare PIN