Provider Demographics
NPI:1447256102
Name:JOHNSON, SANDRA MARCHESE (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:MARCHESE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MARIE
Other - Last Name:MARCHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5921 RILEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-6103
Mailing Address - Country:US
Mailing Address - Phone:479-420-1221
Mailing Address - Fax:
Practice Address - Street 1:5921 RILEY PARK DR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-6103
Practice Address - Country:US
Practice Address - Phone:479-420-1221
Practice Address - Fax:479-646-0133
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1554207ND0101X, 207NP0225X
ARE-1554207ND0900X, 207NI0002X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139972001Medicaid