MEDICARE: MARK D JOHNSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VE0102X	Reproductive Endocrinology Physician	28172	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0738100	OTHER	AZ	BCBS

General Provider Information

NPI Number	:	1033198155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK D JOHNSON MD

Provider Business Mailing Address
First Line	:	1701 E THOMAS RD
Second Line	:	BUILDING 1 SUITE 101
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7646
Country	:	US
Telephone Number	:	602-343-2767
Fax Number	:	602-343-2766

Provider Business Practice Location Address
First Line	:	1701 E THOMAS RD
Second Line	:	BUILDING 1 SUITE 101
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7646
Country	:	US
Telephone Number	:	602-343-2767
Fax Number	:	602-343-2766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2006
Last Update Date	:	07/08/2007

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