Healthcare Provider Details

I. General information

NPI: 1164402681
Provider Name (Legal Business Name): JOHN A. JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 E GREENHURST RD
NAMPA ID
83686
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-7330
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM-10563
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM10563
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: