Basic Information
| Provider Information | |||||||||
| NPI: | 1659331775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 CAISSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664425037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852397155 | ||||||||
| FaxNumber: | 7852397364 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 CAISSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664425037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852397155 | ||||||||
| FaxNumber: | 7852397364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 01/07/2009 | ||||||||
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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 | MD-050714-L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.