Provider Demographics
NPI:1043202393
Name:JOHNSON, MARK ROLFE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROLFE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:113 PLEASANT VALLEY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5683
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:830-214-2576
Practice Address - Street 1:32 W 200 S # 410
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1603
Practice Address - Country:US
Practice Address - Phone:801-960-4890
Practice Address - Fax:801-960-4890
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT184901-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1001176Medicaid
UTE91261Medicare UPIN
UTU000077182Medicare UPIN