Provider Demographics
NPI:1205838653
Name:JOHNSON, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 22ND ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1301
Mailing Address - Country:US
Mailing Address - Phone:806-791-8484
Mailing Address - Fax:806-791-8498
Practice Address - Street 1:3621 22ND ST
Practice Address - Street 2:SUITE 400
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1301
Practice Address - Country:US
Practice Address - Phone:806-791-8484
Practice Address - Fax:806-791-8484
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF9626207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132871806Medicaid
TX132871806Medicaid
TX89W181Medicare ID - Type Unspecified