Provider Demographics
NPI:1689750143
Name:JOHNSON, BENJAMIN H (PT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 W AGUA FRIA FWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3943
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:623-537-5601
Practice Address - Street 1:3010 W AGUA FRIA FWY
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3943
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:623-537-5601
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6763225100000X, 2251G0304X, 2251H1200X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162632Medicaid
AZP00618136OtherRR MEDICARE
AZP00618136OtherRR MEDICARE