Provider Demographics
NPI:1710199666
Name:JOHNSON, MARK HALEY (IDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:HALEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 CHARTER OAK DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-865-0297
Mailing Address - Fax:
Practice Address - Street 1:NLON MEDICAL DEPARTMENT BLDG 76
Practice Address - Street 2:NAVAL SUBMARINE BASE
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-694-2795
Practice Address - Fax:860-694-4326
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman