Healthcare Provider Details

I. General information

NPI: 1720241102
Provider Name (Legal Business Name): MARLA Y JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MASONIC DR
ALEXANDRIA LA
71301-3841
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 318-448-6827
  • Fax:
Mailing address:
  • Phone: 601-984-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number714-L
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number21599
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD.206128
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: