Healthcare Provider Details

I. General information

NPI: 1306892542
Provider Name (Legal Business Name): MICHAEL EUGENE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N DIVISION ST
BLYTHEVILLE AR
72315-1448
US

IV. Provider business mailing address

PO BOX 24086
FORT WORTH TX
76124-1086
US

V. Phone/Fax

Practice location:
  • Phone: 870-838-7460
  • Fax:
Mailing address:
  • Phone: 817-451-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE2802
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: