Provider Demographics
NPI:1144209511
Name:JOHNSON, PHILIP L (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:L
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:PO BOX 52549
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2549
Mailing Address - Country:US
Mailing Address - Phone:928-535-6667
Mailing Address - Fax:928-535-5561
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-537-4375
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16267207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ207979Medicaid
AZ207979Medicaid
AZWDBXJ01Medicare PIN