Provider Demographics
NPI:1811491756
Name:JOHNSON, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
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 1:1211 W WASHINGTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5341
Mailing Address - Country:US
Mailing Address - Phone:208-241-7475
Mailing Address - Fax:
Practice Address - Street 1:70 N MCCLINTOCK DR STE 4
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3711
Practice Address - Country:US
Practice Address - Phone:480-646-4431
Practice Address - Fax:480-464-2338
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-155722084P0800X
AZ679082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry