Provider Demographics
NPI:1477596906
Name:JOHNSON, JAMES T (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
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 1:2200 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1401
Mailing Address - Country:US
Mailing Address - Phone:602-258-6634
Mailing Address - Fax:602-258-4311
Practice Address - Street 1:2200 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1401
Practice Address - Country:US
Practice Address - Phone:602-258-6634
Practice Address - Fax:602-258-4311
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ931560Medicaid
AZ103006Medicare ID - Type Unspecified
AZ931560Medicaid