Basic Information
| Provider Information | |||||||||
| NPI: | 1033105788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., MTM&H | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096621511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 933 RED APPLE RD | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988013370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096656210 | ||||||||
| FaxNumber: | 5096673310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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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 | 207RI0200X | MD60755882 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1033105788 | 05 | WA | MEDICAID | 381440 | 01 | WA | LNI | OTHER |