MEDICARE: DR. EVAN MICHAEL JOHNSON D.O.

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	DO779	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51521836	OTHER	AL	BC/BS PROV. NUMBER

General Provider Information

NPI Number	:	1659399772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAN MICHAEL JOHNSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1049
Second Line	:
City	:	BOAZ
State	:	AL
Zip	:	35957-2201
Country	:	US
Telephone Number	:	256-593-9999
Fax Number	:	256-593-9141

Provider Business Practice Location Address
First Line	:	1180 SARDIS DR
Second Line	:
City	:	SARDIS CITY
State	:	AL
Zip	:	35956-2139
Country	:	US
Telephone Number	:	256-593-9999
Fax Number	:	256-593-9141

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	12/12/2007

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Directions to “ DR. EVAN MICHAEL JOHNSON D.O.” Practice Location

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