Provider Demographics
NPI:1649353855
Name:JOHNSON, MARK LEO (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEO
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 1:3000 MON HEALTH MEDICAL PARK DR STE 3300
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1169
Mailing Address - Country:US
Mailing Address - Phone:304-599-1448
Mailing Address - Fax:304-599-5335
Practice Address - Street 1:3000 MON HEALTH MEDICAL PARK DR STE 3300
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1169
Practice Address - Country:US
Practice Address - Phone:304-599-1448
Practice Address - Fax:304-599-5335
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18363208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV5186C185OtherMEDICARE
001719640OtherBLUE CROSS BLUE SHIELD
WV0126399000Medicaid
WVPO1453582OtherRAILROAD MEDICARE
WVWV5186C185OtherMEDICARE
610308000OtherDOL DEEOIC
WV0126399000Medicaid
610308000OtherOWCP
0221076OtherOHIO MEDICAID
G21872Medicare UPIN
JO7258851Medicare ID - Type Unspecified