Provider Demographics
NPI:1407073687
Name:JOHNSON, ADAM CRANDALL (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:CRANDALL
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 1:2300 E 30TH ST BLDG D
Mailing Address - Street 2:STE 101
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-1400
Mailing Address - Fax:505-564-3202
Practice Address - Street 1:2300 E 30TH ST BLDG D
Practice Address - Street 2:STE 101
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-1400
Practice Address - Fax:505-564-3202
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0310207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98107071Medicaid
NMMD2012-0310OtherMEDICAL LICENSE
FJ3268314OtherDEA
NM98107071Medicaid