Provider Demographics
NPI:1467986307
Name:JOHNSON, ALEX R (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:R
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 1:1318 KANSAS DR
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-2107
Mailing Address - Country:US
Mailing Address - Phone:913-557-5678
Mailing Address - Fax:913-557-5681
Practice Address - Street 1:1318 KANSAS DR
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-2107
Practice Address - Country:US
Practice Address - Phone:913-557-5678
Practice Address - Fax:913-557-5681
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-45104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004763240001Medicaid