Basic Information
| Provider Information | |||||||||
| NPI: | 1306892542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24086 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761241086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1520 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723151448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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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 | 207P00000X | E2802 | AR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5L772 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER | 130216001 | 05 | AR | MEDICAID | P00285103 | 01 | AR | RR MEDICARE | OTHER |