Basic Information
| Provider Information | |||||||||
| NPI: | 1700837622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N. EL DORADO PLACE | ||||||||
| Address2: | F-670 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203244774 | ||||||||
| FaxNumber: | 5203242567 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 E ERICKSON DR | ||||||||
| Address2: | STE 116 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203243940 | ||||||||
| FaxNumber: | 5203243935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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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 | 207R00000X | 41832 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 310321 | 05 | AZ | MEDICAID | 447858 | 05 | AZ | MEDICAID |