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NPI Code Detail

MEDICARE: DR. EDDIE GLEN JOHNSON III M.D.

MEDICARE: DR. EDDIE GLEN JOHNSON III 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
1208D00000XGeneral Practice Physician013312LA

General Provider Information

NPI Number : 1962738500
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. EDDIE GLEN JOHNSON III M.D.
Provider Business Mailing Address
First Line : 107 GRAYSON CIR
Second Line :
City : BOSSIER CITY
State : LA
Zip : 71112-8605
Country : US
Telephone Number : 318-458-2756
Fax Number :
Provider Business Practice Location Address
First Line : 7330 FERN AVE STE 1103
Second Line :
City : SHREVEPORT
State : LA
Zip : 71105-4989
Country : US
Telephone Number : 318-798-0635
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/01/2009
Last Update Date : 11/01/2009

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