Provider Demographics
NPI:1811949498
Name:JOHNSON, ERIC MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MATTHEW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1237
Mailing Address - Country:US
Mailing Address - Phone:651-699-4242
Mailing Address - Fax:
Practice Address - Street 1:2545 CHICAGO AVE
Practice Address - Street 2:SUITE 601
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4522
Practice Address - Country:US
Practice Address - Phone:612-863-7770
Practice Address - Fax:612-863-7772
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36808174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN07D69JOOtherBLUE CROSS BLUE SHIELD
MN32072100OtherWISCONSIN MA
MNHP28250OtherHEALTHPARTNERS
MN107252D417OtherUCARE
MN1711761OtherMEDICA
MN845718200Medicaid
MNF80631Medicare UPIN
MN020001289Medicare ID - Type Unspecified