Provider Demographics
NPI:1194717462
Name:MILES M JOHNSON, M.D. P.A.
Entity type:Organization
Organization Name:MILES M JOHNSON, M.D. P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-251-8055
Mailing Address - Street 1:PO BOX 9450
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0025
Mailing Address - Country:US
Mailing Address - Phone:479-251-8055
Mailing Address - Fax:479-251-1511
Practice Address - Street 1:2820 E MILLENNIUM PL
Practice Address - Street 2:SUITE 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6514
Practice Address - Country:US
Practice Address - Phone:479-251-8055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155016002Medicaid
OK100848150AMedicaid
FLME87648Medicare UPIN
AR5J303Medicare ID - Type UnspecifiedMEDICARE ID
OK100848150AMedicaid
MO2004028838Medicare UPIN
IL036-110426Medicare UPIN
TNMD30810Medicare UPIN
TXH0501Medicare UPIN
AR155016002Medicaid