Provider Demographics
NPI:1518225929
Name:JOHNSON, CLARK A (DPM)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3120 W BELLTOWER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7744
Mailing Address - Country:US
Mailing Address - Phone:208-516-3617
Mailing Address - Fax:208-314-2029
Practice Address - Street 1:3120 W BELLTOWER DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7744
Practice Address - Country:US
Practice Address - Phone:208-516-3617
Practice Address - Fax:208-314-2029
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000757213ES0103X
IDP242213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery