Provider Demographics
NPI:1861601809
Name:JOHNSON, JULIE MARIE (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:SARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3399 E LOUISE DR STE 200
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5212
Practice Address - Country:US
Practice Address - Phone:208-706-2663
Practice Address - Fax:208-489-4300
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC140761207X00000X
IDM-17347207X00000X
RI13537207X00000X
MI4301088471207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC140761OtherCA LICENSE #
NDN717994Medicare PIN