Provider Demographics
NPI:1538234554
Name:JOHNSON, JOHNNY O (DO)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:O
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:J
Other - Middle Name:O
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:15951 LITTLE AXE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9088
Mailing Address - Country:US
Mailing Address - Phone:405-447-0300
Mailing Address - Fax:405-701-7914
Practice Address - Street 1:15951 LITTLE AXE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73026-9088
Practice Address - Country:US
Practice Address - Phone:405-447-0300
Practice Address - Fax:405-701-7914
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4712207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200205340AMedicaid
OK200205340AMedicaid
OKOK401760Medicare PIN