Provider Demographics
NPI:1851812671
Name:JOHNSON, NICK J I (NMD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:J
Last Name:JOHNSON
Suffix:I
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3757 E SEXTON ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-7210
Mailing Address - Country:US
Mailing Address - Phone:480-322-8577
Mailing Address - Fax:
Practice Address - Street 1:9700 N 91ST ST STE A115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5036
Practice Address - Country:US
Practice Address - Phone:480-322-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-01
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17-1629207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ495858Medicaid