Provider Demographics
NPI:1568469526
Name:JOHNSON, MICHAEL DEAN (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:401 BURRO ALLEY
Mailing Address - City:MORENCI
Mailing Address - State:AZ
Mailing Address - Zip Code:85540
Mailing Address - Country:US
Mailing Address - Phone:928-865-9184
Mailing Address - Fax:928-865-7571
Practice Address - Street 1:401 BURRO ALLEY
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540
Practice Address - Country:US
Practice Address - Phone:928-865-9184
Practice Address - Fax:928-865-7571
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32205023Medicaid
080193055OtherRR MEDICARE
080193055OtherRR MEDICARE
347230402Medicare PIN