Provider Demographics
NPI:1356386528
Name:JOHNSON, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
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 1:1515 N HARVARD AVE
Mailing Address - Street 2:STE E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-4957
Mailing Address - Country:US
Mailing Address - Phone:918-832-6049
Mailing Address - Fax:918-832-6055
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:ER DEPT
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-744-3528
Practice Address - Fax:918-744-3529
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24910207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200084670AMedicaid
OKP00327344Medicare PIN
OK200084670AMedicaid
OK24P623501Medicare PIN
LAI41107Medicare UPIN