Provider Demographics
NPI:1629042635
Name:JOHNSON, JOSEPH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21320 N 56TH ST
Mailing Address - Street 2:UNIT 2050
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-5401
Mailing Address - Country:US
Mailing Address - Phone:480-278-0830
Mailing Address - Fax:
Practice Address - Street 1:21320 N 56TH ST
Practice Address - Street 2:UNIT 2050
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-5401
Practice Address - Country:US
Practice Address - Phone:480-278-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11467208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D44079Medicare UPIN