Provider Demographics
NPI:1700837622
Name:JOHNSON, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
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 1:1200 N. EL DORADO PLACE
Mailing Address - Street 2:F-670
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4637
Mailing Address - Country:US
Mailing Address - Phone:520-324-4774
Mailing Address - Fax:520-324-2567
Practice Address - Street 1:5300 E ERICKSON DR
Practice Address - Street 2:STE 116
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2828
Practice Address - Country:US
Practice Address - Phone:520-324-3940
Practice Address - Fax:520-324-3935
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ41832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ310321Medicaid
AZ447858Medicaid