Provider Demographics
NPI:1134168925
Name:JOHNSON, WARREN C (MD, PHD)
Entity type:Individual
Prefix:MR
First Name:WARREN
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11209 N TATUM BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3091
Mailing Address - Country:US
Mailing Address - Phone:602-494-5155
Mailing Address - Fax:602-494-5115
Practice Address - Street 1:11209 N TATUM BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3091
Practice Address - Country:US
Practice Address - Phone:602-494-5155
Practice Address - Fax:602-494-5115
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ396243Medicare ID - Type Unspecified
G45936Medicare UPIN
63711Medicare ID - Type Unspecified