Provider Demographics
NPI:1568531861
Name:DR. MARK W. JOHNSON, PA
Entity Type:Organization
Organization Name:DR. MARK W. JOHNSON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WINTON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:252-638-6177
Mailing Address - Street 1:604 MCCARTHY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5231
Mailing Address - Country:US
Mailing Address - Phone:252-638-6177
Mailing Address - Fax:252-638-5269
Practice Address - Street 1:604 MCCARTHY BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5231
Practice Address - Country:US
Practice Address - Phone:252-638-6177
Practice Address - Fax:252-638-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223S0112X1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0242GOtherBCBS
NC790242GMedicaid
NC0242GOtherBCBS