Basic Information
| Provider Information | |||||||||
| NPI: | 1679535991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512451130 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 45735 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 45749 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QG0300X | 15917 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | HP38799 | 01 | MN | HEALTH PARTNERS | OTHER | P00047499 | 01 | MN | RAILROAD MEDICARE | OTHER | 66-06190 | 01 | MN | MEDICA URGENT CARE | OTHER | 072K4J0 | 01 | MN | BLUE CROSS | OTHER | 171680 | 01 | MN | UCARE MINNESOTA | OTHER | 1882619 | 01 | MN | AMERICA'S PPO | OTHER | 2110090 | 01 | MN | FIRST HEALTH GROUP | OTHER | 34407600 | 05 | WI | MEDICAID | 607632700 | 01 | MN | GROUP HEALTH EAU CLAIRE | OTHER | NA9141035345 | 01 | MN | PREFERRED ONE | OTHER | 01-18712 | 01 | MN | MEDICA | OTHER | 607632700 | 05 | MN | MEDICAID |