Provider Demographics
NPI:1851415509
Name:JOHNSON, ELIJAH MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIJAH
Middle Name:MICHAEL
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 SHADOW LANE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-702-3834
Mailing Address - Fax:702-383-0526
Practice Address - Street 1:710 CORONADO CENTER DR STE 200-EJ
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4289
Practice Address - Country:US
Practice Address - Phone:702-334-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13190208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLL1489OtherMEDICAL LICENSE
NVASO2532198955OtherDEA CERTIFICATE