Provider Demographics
NPI:1013161363
Name:PRIMARY CARE OF ARKANSAS CHRYSTAL JOHNSON MD
Entity Type:Organization
Organization Name:PRIMARY CARE OF ARKANSAS CHRYSTAL JOHNSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRYSTAL
Authorized Official - Middle Name:DIAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-666-6100
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 515
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-666-6100
Mailing Address - Fax:501-666-6107
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-666-6100
Practice Address - Fax:501-666-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150345001Medicaid
AR181136002Medicaid
AR04010017400OtherQUAL CHOICE
AR04010017400OtherQUAL CHOICE
AR181136002Medicaid
AR7208150001Medicare NSC