Provider Demographics
NPI:1386648129
Name:JOHNSON, LORI R (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4573
Mailing Address - Fax:318-798-4651
Practice Address - Street 1:1455 E BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4573
Practice Address - Fax:318-798-4651
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023711207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486957Medicaid
LA1053315846OtherGROUP NPI NUMBER
LA030005408OtherRAILROAD MEDICARE NUMBER
LAH78210Medicare UPIN
LA1486957Medicaid
LA4E876Medicare ID - Type Unspecified