Provider Demographics
NPI:1134123813
Name:JOHNSON, MICHAEL BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
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 1:409 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3108
Mailing Address - Country:US
Mailing Address - Phone:501-664-6980
Mailing Address - Fax:501-664-4738
Practice Address - Street 1:409 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3108
Practice Address - Country:US
Practice Address - Phone:501-664-6980
Practice Address - Fax:501-664-4738
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7853174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117492001Medicaid
ARE66992Medicare UPIN
AR53658Medicare ID - Type Unspecified