Provider Demographics
NPI:1578670931
Name:JOHNSON, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 23831
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07189-0831
Mailing Address - Country:US
Mailing Address - Phone:973-971-7184
Mailing Address - Fax:973-290-8349
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-971-7165
Practice Address - Fax:973-290-7521
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08685600207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02784701Medicaid
NYI59211Medicare UPIN
NY02784701Medicaid