Provider Demographics
NPI:1033105788
Name:JOHNSON, MARK DOUGLAS (MD, MTM&H)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, MTM&H
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-662-1511
Mailing Address - Fax:
Practice Address - Street 1:933 RED APPLE RD
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3370
Practice Address - Country:US
Practice Address - Phone:509-665-6210
Practice Address - Fax:509-667-3310
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60755882207RI0200X
VA0101238561207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033105788Medicaid
WA381440OtherLNI