Provider Demographics
NPI:1962555847
Name:JOHNSON, GARY N (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:N
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:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0997
Mailing Address - Country:US
Mailing Address - Phone:701-530-6500
Mailing Address - Fax:
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4094207LP2900X, 207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP00227623OtherRAILROAD MEDICARE
ND1452790Medicaid
NDP00227623OtherRAILROAD MEDICARE
ND1452790Medicaid
ND1452790Medicaid