Provider Demographics
NPI:1730475815
Name:JOHNSON, MARC EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:EDWARD
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 1:1350 S MAIN ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7663
Mailing Address - Country:US
Mailing Address - Phone:601-695-0397
Mailing Address - Fax:
Practice Address - Street 1:1350 S MAIN ST STE 1600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7663
Practice Address - Country:US
Practice Address - Phone:817-702-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23972207Q00000X
ARE8843207Q00000X
TXS-7461207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine