Provider Demographics
NPI:1770551095
Name:JOHNSON, STEPHEN M (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10300 N ILLINOIS ST STE 1040
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1167
Mailing Address - Country:US
Mailing Address - Phone:317-817-1765
Mailing Address - Fax:317-817-1767
Practice Address - Street 1:10300 N ILLINOIS ST STE 1040
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1167
Practice Address - Country:US
Practice Address - Phone:317-817-1765
Practice Address - Fax:317-817-1767
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027083207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100072660AMedicaid
INM400066996Medicare PIN
IN316650AMedicare PIN
E06470Medicare UPIN