Provider Demographics
NPI:1336129667
Name:JOHNSON, CHARLES H (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
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 1:830 AINSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1630
Mailing Address - Country:US
Mailing Address - Phone:928-776-0325
Mailing Address - Fax:928-776-0405
Practice Address - Street 1:830 AINSWORTH DRIVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1614
Practice Address - Country:US
Practice Address - Phone:928-776-0325
Practice Address - Fax:928-776-0405
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17178207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ282731Medicaid
AZ282731Medicaid
AZ119577Medicare PIN
AZE39618Medicare UPIN