Provider Demographics
NPI:1578586673
Name:JOHNSON, MARY (DPM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1218 N FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3109
Mailing Address - Country:US
Mailing Address - Phone:918-341-6821
Mailing Address - Fax:918-342-8128
Practice Address - Street 1:1218 N FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3109
Practice Address - Country:US
Practice Address - Phone:918-341-6821
Practice Address - Fax:918-342-8128
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK231213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V01033Medicare UPIN