Healthcare Provider Details

I. General information

NPI: 1467986307
Provider Name (Legal Business Name): ALEX R JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 10/06/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 KANSAS DR
PAOLA KS
66071-2107
US

IV. Provider business mailing address

1318 KANSAS DR
PAOLA KS
66071-2107
US

V. Phone/Fax

Practice location:
  • Phone: 913-557-5678
  • Fax: 913-557-5681
Mailing address:
  • Phone: 913-557-5678
  • Fax: 913-557-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-45104
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: