Healthcare Provider Details

I. General information

NPI: 1033198155
Provider Name (Legal Business Name): MARK D JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E THOMAS RD BUILDING 1 SUITE 101
PHOENIX AZ
85016-7646
US

IV. Provider business mailing address

1701 E THOMAS RD BUILDING 1 SUITE 101
PHOENIX AZ
85016-7646
US

V. Phone/Fax

Practice location:
  • Phone: 602-343-2767
  • Fax: 602-343-2766
Mailing address:
  • Phone: 602-343-2767
  • Fax: 602-343-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number28172
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: