Provider Demographics
NPI:1558381376
Name:MARK A JOHNSON, MD, PA
Entity Type:Organization
Organization Name:MARK A JOHNSON, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PORVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-271-0665
Mailing Address - Street 1:15713 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-3181
Mailing Address - Country:US
Mailing Address - Phone:281-723-6926
Mailing Address - Fax:844-855-6799
Practice Address - Street 1:100 MEDICAL CENTER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2821
Practice Address - Country:US
Practice Address - Phone:936-271-0665
Practice Address - Fax:936-271-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00469VMedicare PIN