Provider Demographics
NPI:1952310831
Name:JOHNSON, LEVIE G (MD)
Entity Type:Individual
Prefix:
First Name:LEVIE
Middle Name:G
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 1:1236 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-9212
Mailing Address - Country:US
Mailing Address - Phone:985-856-2623
Mailing Address - Fax:
Practice Address - Street 1:108 6TH AVE
Practice Address - Street 2:
Practice Address - City:KINDER
Practice Address - State:LA
Practice Address - Zip Code:70648
Practice Address - Country:US
Practice Address - Phone:337-738-9476
Practice Address - Fax:337-738-9410
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08482R282NR1301X
LAMD.08482R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1902594Medicaid
LAE75297Medicare UPIN
LA1902594Medicaid