Basic Information
| Provider Information | |||||||||
| NPI: | 1467986307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ALEX | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1318 KANSAS DR | ||||||||
| Address2: | |||||||||
| City: | PAOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660712107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135575678 | ||||||||
| FaxNumber: | 9135575681 | ||||||||
| Practice Location | |||||||||
| Address1: | 1318 KANSAS DR | ||||||||
| Address2: | |||||||||
| City: | PAOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660712107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135575678 | ||||||||
| FaxNumber: | 9135575681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-45104 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30004763240001 | 05 | KS | MEDICAID |