Healthcare Provider Details

I. General information

NPI: 1356563241
Provider Name (Legal Business Name): GIL JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 A COLLEGE AVE
CONWAY AR
72034-6135
US

IV. Provider business mailing address

2511 A COLLEGE AVE
CONWAY AR
72034-6135
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-6041
  • Fax: 501-327-6043
Mailing address:
  • Phone: 501-327-6041
  • Fax: 501-327-6043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMC1518
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: