Provider Demographics
NPI:1669517611
Name:JOHNSON, JASON (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
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 1:200 W. HOSPITAL DR.
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:95491-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:
Practice Address - Street 1:200 W. HOSPITAL DR.
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:95491-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40617207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1629236716Medicaid
AZ353135Medicaid
AZ1295993376Medicaid
AZ1427335140Medicaid
AZ1427335181Medicaid
AZ353135Medicaid
AZ1427335140Medicaid