Provider Demographics
NPI:1457896789
Name:JOHNSON, ALI N (PODOLOGIST)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PODOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BENTON RD
Mailing Address - Street 2:D
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-4700
Mailing Address - Country:US
Mailing Address - Phone:318-626-5052
Mailing Address - Fax:
Practice Address - Street 1:450 BENTON RD
Practice Address - Street 2:SUITE D
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-4700
Practice Address - Country:US
Practice Address - Phone:318-626-5052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0087654213EP0504X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine