Provider Demographics
NPI:1669578357
Name:JOHNSON, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 YUBA ST
Mailing Address - Street 2:SUITE 144
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-4838
Mailing Address - Country:US
Mailing Address - Phone:530-741-6245
Mailing Address - Fax:530-741-9274
Practice Address - Street 1:724 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5646
Practice Address - Country:US
Practice Address - Phone:530-749-3242
Practice Address - Fax:530-749-3248
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044906207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0197072OtherSTATE L&I PROVIDER #
WA0227846OtherLIWA
WA8429763Medicaid
WA3952JOOtherBSWA
WA3952JOOtherBSWA
WAH19636Medicare UPIN
WA8429763Medicaid