Provider Demographics
NPI:1467457747
Name:JOHNSON, MYSTIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:MYSTIE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9305 W THOMAS RD
Mailing Address - Street 2:STE 155
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3328
Mailing Address - Country:US
Mailing Address - Phone:623-936-1780
Mailing Address - Fax:623-936-9116
Practice Address - Street 1:9305 W THOMAS RD
Practice Address - Street 2:STE 155
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3328
Practice Address - Country:US
Practice Address - Phone:623-936-1780
Practice Address - Fax:623-936-9116
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27778207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH72606Medicare UPIN