Provider Demographics
NPI:1124027446
Name:JOHNSON, MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
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 1:1700 RING RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9497
Mailing Address - Country:US
Mailing Address - Phone:270-769-5551
Mailing Address - Fax:270-765-3919
Practice Address - Street 1:1700 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9497
Practice Address - Country:US
Practice Address - Phone:270-769-5551
Practice Address - Fax:270-765-3919
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000045853OtherANTHEM BCBS
KY1048777OtherPASSPORT
KY64148042Medicaid
KY000000045853OtherANTHEM BCBS
KYC68089Medicare UPIN