Healthcare Provider Details

I. General information

NPI: 1679576243
Provider Name (Legal Business Name): GLENDA JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 04/25/2006

III. Provider practice location address

2400 HOSPITAL DR SUITE 240
BOSSIER CITY LA
71111-2385
US

IV. Provider business mailing address

2400 HOSPITAL DR SUITE 240
BOSSIER CITY LA
71111-2385
US

V. Phone/Fax

Practice location:
  • Phone: 318-742-5800
  • Fax: 318-741-3902
Mailing address:
  • Phone: 318-742-5800
  • Fax: 318-741-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number14496R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: