Provider Demographics
NPI:1497836563
Name:JOHNSON, CHRYSTAL DIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRYSTAL
Middle Name:DIAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHRYSTAL
Other - Middle Name:DIAN
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20602 ARCH STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:HENSLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72065-9442
Mailing Address - Country:US
Mailing Address - Phone:501-262-2602
Mailing Address - Fax:501-891-5672
Practice Address - Street 1:20602 ARCH STREET PIKE
Practice Address - Street 2:
Practice Address - City:HENSLEY
Practice Address - State:AR
Practice Address - Zip Code:72065-9442
Practice Address - Country:US
Practice Address - Phone:501-262-2602
Practice Address - Fax:501-891-5672
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04010017400OtherQUALCHOICE
AR150345001Medicaid
ARP000900296OtherRR MEDICARE
AR5M652OtherBLUE CROSS BLUE SHIELD
AR1670460OtherUNITED HEALTHCARE
H98484Medicare UPIN
AR1670460OtherUNITED HEALTHCARE