Provider Demographics
NPI:1073543229
Name:JOHNSON, MARCUS A (MD)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:A
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 1:2201 SUN RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404
Mailing Address - Country:US
Mailing Address - Phone:406-452-9927
Mailing Address - Fax:
Practice Address - Street 1:2201 SUN RIVER RD
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404
Practice Address - Country:US
Practice Address - Phone:406-452-9927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT3401207Q00000X
MT3401208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0083164Medicaid
MT0083164Medicaid
MT011001414Medicare PIN
MT000084258Medicare ID - Type Unspecified