Provider Demographics
NPI:1669574497
Name:JOHNSON, JAY C (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:C
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 394
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-0394
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-259-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000449542085R0202X
CO463692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00664636OtherRAILROAD MEDICARE
AZ341184Medicaid
CO51508851Medicaid
NM46280570Medicaid
CO51508851Medicaid