Provider Demographics
NPI:1568576320
Name:JOHNSEN, STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:222 W THOMAS RD
Practice Address - Street 2:SUITE 304
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4419
Practice Address - Country:US
Practice Address - Phone:602-406-3800
Practice Address - Fax:602-406-3810
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63242084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ412007Medicaid
AZ78069Medicare ID - Type UnspecifiedMEDICARE #