MEDICARE: GLENNA WONG JOHNSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	34716	OK

General Provider Information

NPI Number	:	1013571256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENNA WONG JOHNSON MD

Provider Business Mailing Address
First Line	:	7501 RIVERSIDE PKWY
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-5056
Country	:	US
Telephone Number	:	918-710-4200
Fax Number	:	918-403-6331

Provider Business Practice Location Address
First Line	:	5635 N MLK JR BLVD
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74126-6409
Country	:	US
Telephone Number	:	918-398-9460
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	09/03/2025

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