Provider Demographics
NPI:1942291521
Name:JOHNSON, MIERS C (MD)
Entity Type:Individual
Prefix:DR
First Name:MIERS
Middle Name:C
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-288-4700
Practice Address - Fax:208-288-4720
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5750207X00000X
IDM-5750207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID33548OtherBLUE CROSS
ID000010006018OtherBLUE SHIELD
ID002364900Medicaid
ID000010006017OtherBLUE SHIELD
ID57505OtherBLUE CROSS
ID200012693OtherRAILROAD MEDICARE
E11639Medicare UPIN
ID002364900Medicaid