MEDICARE: DR. CHRYSTAL DIAN JOHNSON M.D.

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	207Q00000X	Family Medicine Physician	E-3700	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P000900296	OTHER	AR	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04010017400	OTHER	AR	QUALCHOICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	5M652	OTHER	AR	BLUE CROSS BLUE SHIELD
5	1670460	OTHER	AR	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1497836563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRYSTAL DIAN JOHNSON M.D.

Provider Business Mailing Address
First Line	:	20602 ARCH STREET PIKE
Second Line	:
City	:	HENSLEY
State	:	AR
Zip	:	72065-9442
Country	:	US
Telephone Number	:	501-262-2602
Fax Number	:	501-891-5672

Provider Business Practice Location Address
First Line	:	20602 ARCH STREET PIKE
Second Line	:
City	:	HENSLEY
State	:	AR
Zip	:	72065-9442
Country	:	US
Telephone Number	:	501-262-2602
Fax Number	:	501-891-5672

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	10/25/2023

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