Provider Demographics
NPI:1619545282
Name:JOHNSON, ZACHARY JAY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:JAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 S COUNTRY CLUB RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85714-2227
Mailing Address - Country:US
Mailing Address - Phone:520-626-4555
Mailing Address - Fax:
Practice Address - Street 1:3950 S COUNTRY CLUB RD STE 200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-2227
Practice Address - Country:US
Practice Address - Phone:520-626-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZR80226207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program