Provider Demographics
NPI:1275514978
Name:JOHNSON, EDDIE D (MD)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:D
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 1:2508 BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-671-1291
Mailing Address - Fax:318-688-6014
Practice Address - Street 1:2508 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 102
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-671-1291
Practice Address - Fax:318-688-6014
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1180289Medicaid
B60706Medicare UPIN
LA5K061BD08Medicare PIN
LA5K061Medicare PIN