Provider Demographics
NPI:1659356921
Name:JOHNSON, PHILLIP M (MD)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 HIGHLANDER PT DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FLOYDS KNOBS
Mailing Address - State:IN
Mailing Address - Zip Code:47119
Mailing Address - Country:US
Mailing Address - Phone:812-923-4106
Mailing Address - Fax:812-923-4100
Practice Address - Street 1:800 HIGHLANDER PT DR
Practice Address - Street 2:STE 300
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119
Practice Address - Country:US
Practice Address - Phone:812-923-4106
Practice Address - Fax:812-923-4100
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100116730AMedicaid
IN243940CMedicare ID - Type Unspecified