Basic Information
| Provider Information | |||||||||
| NPI: | 1225023773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3633 CENTRAL AVE | ||||||||
| Address2: | SUITE N | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016236100 | ||||||||
| FaxNumber: | 5016236187 | ||||||||
| Practice Location | |||||||||
| Address1: | 3633 CENTRAL AVE | ||||||||
| Address2: | SUITE N | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016236100 | ||||||||
| FaxNumber: | 5016236187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 018949 | LA | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | M6214 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | 207NI0002X | 15320 | MS | N | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology | 207N00000X | E-5113 | AR | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 166140001 | 05 | AR | MEDICAID | E5113 | 01 | AR | STATE LICENSE | OTHER |