Basic Information
| Provider Information | |||||||||
| NPI: | 1013960269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | GREG | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CAREW STREET | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739919 | ||||||||
| FaxNumber: | 2603736315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 02001531 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | P00895098 | 01 | IN | R.R. MEDICARE | OTHER | 000000675115 | 01 | IN | ANTHEM | OTHER | 200015220 | 05 | IN | MEDICAID |