Provider Demographics
NPI:1942263769
Name:JOHNSON, EDEN ENRIQUEZ (MD)
Entity Type:Individual
Prefix:MS
First Name:EDEN
Middle Name:ENRIQUEZ
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4041 LYNN COURT DRIVE
Mailing Address - Street 2:SUITE 305, C/O ROBERT DESKINS, CPA
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055
Mailing Address - Country:US
Mailing Address - Phone:928-606-3887
Mailing Address - Fax:
Practice Address - Street 1:198 S SKILL CENTER RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:888-431-4096
Practice Address - Fax:520-562-3415
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA180192084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry