Provider Demographics
NPI:1407825045
Name:JOHNSON, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
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 1:6301 S MCCLINTOCK DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3392
Mailing Address - Country:US
Mailing Address - Phone:480-897-0242
Mailing Address - Fax:480-897-0244
Practice Address - Street 1:18699 N 67TH AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7140
Practice Address - Country:US
Practice Address - Phone:623-362-2266
Practice Address - Fax:623-362-2412
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17150207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ273053Medicaid
AZ273053Medicaid