Provider Demographics
NPI:1598765497
Name:JOHNSON, JON MARK SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MARK
Last Name:JOHNSON
Suffix:SR
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 1:608 S HESTER ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4516
Mailing Address - Country:US
Mailing Address - Phone:405-377-8000
Mailing Address - Fax:405-377-8040
Practice Address - Street 1:608 S HESTER ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4516
Practice Address - Country:US
Practice Address - Phone:405-377-8000
Practice Address - Fax:405-377-8040
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100125430BMedicaid
OK100125430BMedicaid
OK731255413Medicare ID - Type UnspecifiedTAX ID