Provider Demographics
NPI:1346306974
Name:SARA L. JOHNSON, MD
Entity Type:Organization
Organization Name:SARA L. JOHNSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-733-2885
Mailing Address - Street 1:496 SHOUP AVE W
Mailing Address - Street 2:SUITE E
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5043
Mailing Address - Country:US
Mailing Address - Phone:208-733-2885
Mailing Address - Fax:208-734-3352
Practice Address - Street 1:496 SHOUP AVE W
Practice Address - Street 2:SUITE E
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5043
Practice Address - Country:US
Practice Address - Phone:208-733-2885
Practice Address - Fax:208-734-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4188261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8H757OtherBLUE CROSS OF IDAHO
ID000010017978OtherREGENCE BLUE SHIELD OF ID
ID1375273Medicare ID - Type Unspecified