Healthcare Provider Details

I. General information

NPI: 1902827694
Provider Name (Legal Business Name): COURTNEY R JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 S DOBSON RD SUITE 501
MESA AZ
85202-4768
US

IV. Provider business mailing address

1432 S DOBSON RD SUITE 501
MESA AZ
85202-4768
US

V. Phone/Fax

Practice location:
  • Phone: 480-412-7457
  • Fax: 480-412-7475
Mailing address:
  • Phone: 480-412-7457
  • Fax: 480-412-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2000213
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number19112
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: