Provider Demographics
NPI:1609869643
Name:JOHNSON, MICHAEL MACKENZIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MACKENZIE
Last Name:JOHNSON
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 1:14678 N DEL WEBB BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-2137
Mailing Address - Country:US
Mailing Address - Phone:623-933-8289
Mailing Address - Fax:623-933-2596
Practice Address - Street 1:14678 N DEL WEBB BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-2137
Practice Address - Country:US
Practice Address - Phone:623-933-8289
Practice Address - Fax:623-933-2596
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0054230OtherBLUE CROSS BLUE SHIELD
AZ110061076OtherRAILROAD MEDICARE
AZ110061076OtherRAILROAD MEDICARE
AZWCJBJ03Medicare PIN