Healthcare Provider Details

I. General information

NPI: 1427041201
Provider Name (Legal Business Name): STEPHEN C JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 N 6TH E
MOUNTAIN HOME ID
83647-2207
US

IV. Provider business mailing address

PO BOX 507
MOUNTAIN HOME ID
83647-0507
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-41
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: