Healthcare Provider Details

I. General information

NPI: 1659399772
Provider Name (Legal Business Name): EVAN MICHAEL JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 SARDIS DR
SARDIS CITY AL
35956-2139
US

IV. Provider business mailing address

PO BOX 1049
BOAZ AL
35957-2201
US

V. Phone/Fax

Practice location:
  • Phone: 256-593-9999
  • Fax: 256-593-9141
Mailing address:
  • Phone: 256-593-9999
  • Fax: 256-593-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO779
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: