Provider Demographics
NPI:1659368629
Name:JOHNSON, STEPHANIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:KIRTS-JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2794 BUTTERCUP CT E
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3041
Mailing Address - Country:US
Mailing Address - Phone:812-418-4230
Mailing Address - Fax:812-418-4230
Practice Address - Street 1:301 HENRY ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1030
Practice Address - Country:US
Practice Address - Phone:812-352-4454
Practice Address - Fax:812-418-4230
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054624A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200349990AMedicaid
IN247870AMedicare PIN
IN940540BSMedicare PIN
INH51076Medicare UPIN