Healthcare Provider Details

I. General information

NPI: 1962738500
Provider Name (Legal Business Name): EDDIE GLEN JOHNSON III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2009
Last Update Date: 11/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 FERN AVE STE 1103
SHREVEPORT LA
71105-4989
US

IV. Provider business mailing address

107 GRAYSON CIR
BOSSIER CITY LA
71112-8605
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-0635
  • Fax:
Mailing address:
  • Phone: 318-458-2756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number013312
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: