Provider Demographics
NPI:1053334615
Name:JOHNSON, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:15713 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-3181
Mailing Address - Country:US
Mailing Address - Phone:936-271-0665
Mailing Address - Fax:844-855-6799
Practice Address - Street 1:100 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 100
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:936-271-0665
Practice Address - Fax:844-855-6799
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2022-11-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXJ9115208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG10335Medicare UPIN
TX8A8789Medicare PIN