Provider Demographics
NPI:1932107505
Name:JOHNSON, GLENN M (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
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 1:2820 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6302
Mailing Address - Country:US
Mailing Address - Phone:504-821-8158
Mailing Address - Fax:504-821-8158
Practice Address - Street 1:2820 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6302
Practice Address - Country:US
Practice Address - Phone:504-821-8158
Practice Address - Fax:504-821-8158
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014753174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA52424B368Medicare ID - Type Unspecified
LAB63852Medicare UPIN