MEDICARE: GLENN M JOHNSON M.D.

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	174400000X	Specialist	014753	LA
2	207RC0000X	Cardiovascular Disease Physician	014753	LA

General Provider Information

NPI Number	:	1932107505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN M JOHNSON M.D.

Provider Business Mailing Address
First Line	:	2820 CANAL ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-6302
Country	:	US
Telephone Number	:	504-821-8158
Fax Number	:	504-821-8158

Provider Business Practice Location Address
First Line	:	2820 CANAL ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-6302
Country	:	US
Telephone Number	:	504-821-8158
Fax Number	:	504-821-8158

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	03/06/2019

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