Provider Demographics
NPI:1083615520
Name:JOHNSON, MARISA (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 LINE AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4628
Mailing Address - Country:US
Mailing Address - Phone:318-221-2707
Mailing Address - Fax:313-221-2709
Practice Address - Street 1:1303 LINE AVE
Practice Address - Street 2:STE 400
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4628
Practice Address - Country:US
Practice Address - Phone:318-221-2707
Practice Address - Fax:313-221-2709
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6967207RN0300X
LA023908207RN0300X
LAMD.023908207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146986802Medicaid
LA1487481Medicaid
TX146986802Medicaid
LA1487481Medicaid
LA4A598CC98Medicare PIN