Provider Demographics
NPI:1295708428
Name:PAINE, JOHNNY ROSS (DO)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:ROSS
Last Name:PAINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0639
Mailing Address - Country:US
Mailing Address - Phone:414-247-9005
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:15 SILVER OAK DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4584
Practice Address - Country:US
Practice Address - Phone:972-533-1767
Practice Address - Fax:501-279-1217
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4621207Q00000X
OK3902207QA0505X
ARR-3454207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197838902Medicaid
OK1203902Medicaid
AR103756003Medicaid
TX197838901Medicaid
TX197838901Medicaid
AR103756003Medicaid
TX197838902Medicaid
AR323068YJX8Medicare PIN
OK53931Medicare ID - Type Unspecified