Provider Demographics
NPI:1952320640
Name:JOHNSON, GAIL R (DPM)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 E MILLENNIUM PL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6514
Mailing Address - Country:US
Mailing Address - Phone:479-582-1199
Mailing Address - Fax:479-582-1194
Practice Address - Street 1:2828 E MILLENNIUM PL
Practice Address - Street 2:SUITE 2
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6514
Practice Address - Country:US
Practice Address - Phone:479-582-1199
Practice Address - Fax:479-582-1194
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR185213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184OtherBLUE CROSS
AR5X001OtherBLUE SHIELD
AR184OtherBLUE CROSS
ARU32771Medicare UPIN
AR5X001OtherBLUE SHIELD