Provider Demographics
NPI:1588692628
Name:JOHNSON, JOHNNY EMANUEL JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:EMANUEL
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4545 E 9TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-3903
Mailing Address - Country:US
Mailing Address - Phone:303-261-3825
Mailing Address - Fax:303-261-3827
Practice Address - Street 1:4545 E 9TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3903
Practice Address - Country:US
Practice Address - Phone:303-261-3825
Practice Address - Fax:303-261-3827
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22809207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01228097Medicaid
COD28307Medicare UPIN
CO46651Medicare ID - Type Unspecified