Provider Demographics
NPI:1033198155
Name:JOHNSON, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1701 E THOMAS RD
Mailing Address - Street 2:BUILDING 1 SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7646
Mailing Address - Country:US
Mailing Address - Phone:602-343-2767
Mailing Address - Fax:602-343-2766
Practice Address - Street 1:1701 E THOMAS RD
Practice Address - Street 2:BUILDING 1 SUITE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7646
Practice Address - Country:US
Practice Address - Phone:602-343-2767
Practice Address - Fax:602-343-2766
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ28172207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0738100OtherBCBS
B45768Medicare UPIN