Healthcare Provider Details

I. General information

NPI: 1073697447
Provider Name (Legal Business Name): CAROLYN JEAN JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAJO ROUTE 64
TSAILE AZ
86556
US

IV. Provider business mailing address

PO DRAWER PH
CHINLE AZ
86503
US

V. Phone/Fax

Practice location:
  • Phone: 928-724-3600
  • Fax: 928-724-3605
Mailing address:
  • Phone: 928-674-7166
  • Fax: 928-674-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39380
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: