Provider Demographics
NPI:1083602882
Name:JOHNSON, JOHN S (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
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 1:111 S MAIN ST
Mailing Address - Street 2:PO BOX 580
Mailing Address - City:LEACHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72438-0580
Mailing Address - Country:US
Mailing Address - Phone:870-539-1115
Mailing Address - Fax:870-539-1125
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEACHVILLE
Practice Address - State:AR
Practice Address - Zip Code:72438
Practice Address - Country:US
Practice Address - Phone:870-539-1115
Practice Address - Fax:870-539-1125
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129915001Medicaid
ARG35364Medicare UPIN
AR5K184Medicare ID - Type Unspecified