Provider Demographics
NPI:1891784245
Name:JOHNSON, ELIZABETH JO (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:401 BROCKMAN LOOP
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-6161
Practice Address - Country:US
Practice Address - Phone:208-933-2612
Practice Address - Fax:208-933-2614
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005359Medicare PIN
IDH64628Medicare UPIN
ID1130306Medicare ID - Type UnspecifiedINDIVIDUAL