Provider Demographics
NPI:1326017005
Name:JOHNSON, ANTHONY DALE (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DALE
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 1:500 S. UNIVERSITY AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-664-4117
Mailing Address - Fax:501-664-1137
Practice Address - Street 1:500 S. UNIVERSITY AVE
Practice Address - Street 2:STE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-664-4117
Practice Address - Fax:501-664-1137
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5803208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105371001Medicaid
AR105371001Medicaid
AR5-2675Medicare ID - Type Unspecified
ARFO1523Medicare UPIN