Provider Demographics
NPI:1740246362
Name:JOHNSON, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
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 1:820 S MCCLELLAN
Mailing Address - Street 2:#LL10
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204
Mailing Address - Country:US
Mailing Address - Phone:509-353-3973
Mailing Address - Fax:509-838-8275
Practice Address - Street 1:820 S MCCLELLAN
Practice Address - Street 2:#LL10
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-353-3973
Practice Address - Fax:509-838-8275
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016683207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1647601Medicaid
WA319202610Medicare ID - Type Unspecified
WA1647601Medicaid