Basic Information
| Provider Information | |||||||||
| NPI: | 1568469526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | 401 BURRO ALLEY | ||||||||
| City: | MORENCI | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288659184 | ||||||||
| FaxNumber: | 9288657571 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BURRO ALLEY | ||||||||
| Address2: | |||||||||
| City: | MORENCI | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288659184 | ||||||||
| FaxNumber: | 9288657571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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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 | 207Q00000X | 2002-0054 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32205023 | 05 | NM | MEDICAID | 080193055 | 01 | RR MEDICARE | OTHER |