Provider Demographics
NPI:1265451918
Name:JOHNSON, MARC ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ALEXANDER
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00106207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911572Medicaid
SCN00103Medicaid
NC1265451918Medicaid
NY01408680Medicaid
NY00669Medicare PIN
NY0271HTMedicare PIN
NC1265451918Medicaid
NY02711CMedicare PIN
NY01408680Medicaid
NYF19929Medicare UPIN