Provider Demographics
NPI:1437171725
Name:JOHNSON, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
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:PO BOX 8099
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-8099
Mailing Address - Country:US
Mailing Address - Phone:870-932-4211
Mailing Address - Fax:870-931-9141
Practice Address - Street 1:1100 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4314
Practice Address - Country:US
Practice Address - Phone:870-932-4211
Practice Address - Fax:870-931-9141
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4605207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC68583Medicare UPIN
AR52679Medicare ID - Type Unspecified