Healthcare Provider Details

I. General information

NPI: 1750598710
Provider Name (Legal Business Name): MARK C JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 3014
CINCINNATI OH
45229-3039
US

IV. Provider business mailing address

3333 BURNET AVE ML 3014
CINCINNATI OH
45229-3039
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4788
  • Fax: 513-636-4283
Mailing address:
  • Phone: 513-636-4788
  • Fax: 513-636-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35.090789
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: