Provider Demographics
NPI:1790763837
Name:JOHNSON, JEFFREY LOREN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LOREN
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 1:4101 WAGON TRAIL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-4426
Mailing Address - Country:US
Mailing Address - Phone:702-942-4123
Mailing Address - Fax:702-942-4124
Practice Address - Street 1:3061 S MARYLAND PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2298
Practice Address - Country:US
Practice Address - Phone:702-731-2888
Practice Address - Fax:702-696-9289
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV74122085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV7306OtherBLUE
NV2019713Medicaid
NVNV7306OtherBLUE
F84803Medicare UPIN