Provider Demographics
NPI:1730475815
Name:JOHNSON, MARC EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-4007
Mailing Address - Country:US
Mailing Address - Phone:601-695-0397
Mailing Address - Fax:
Practice Address - Street 1:950 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2644
Practice Address - Country:US
Practice Address - Phone:601-833-7973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23972207Q00000X
ARE8843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine