1669578357 NPI number — MARK E JOHNSON MD

Table of content: MARK E JOHNSON MD (NPI 1669578357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669578357 NPI number — MARK E JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669578357
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 YUBA ST
Provider Second Line Business Mailing Address:
SUITE 144
Provider Business Mailing Address City Name:
MARYSVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95901-4838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-741-6245
Provider Business Mailing Address Fax Number:
530-741-9274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
724 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYSVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95901-5646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-749-3242
Provider Business Practice Location Address Fax Number:
530-749-3248
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MD00044906 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0197072 . This is a "STATE L&I PROVIDER #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0227846 . This is a "LIWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8429763 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3952JO . This is a "BSWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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