Individual
DEREK B JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
454 SAINT MICHAELS DR STE 200, SANTA FE, NM 87505
(505) 303-5000
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
224930
MA
208600000X
Surgery Physician
49065
WI
208600000X
Surgery Physician
Primary
MD2018-0748
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
057945003
MEDICARE PTAN
WI
05
—
34863900
—
WI
Enumeration date
06/01/2006
Last updated
08/28/2018
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