Provider Demographics
NPI:1811908445
Name:JOHNSON, SHAWN MARK (MD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MARK
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:PO BOX 80070
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-0070
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:5001 US HIGHWAY 30 W STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9701
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061755A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200812580Medicaid
MI1811908445Medicaid
OH2658520Medicaid
INP00379093Medicare PIN
I51121Medicare UPIN
OH2658520Medicaid
MI1811908445Medicaid
IN981270PPMedicare PIN
IN136270IIMedicare PIN