Provider Demographics
NPI:1306920202
Name:JOHNSON, MAYBEN COLE (DO)
Entity type:Individual
Prefix:DR
First Name:MAYBEN
Middle Name:COLE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-1112
Mailing Address - Fax:208-732-1212
Practice Address - Street 1:526 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-1112
Practice Address - Fax:208-732-1212
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS3788OtherBLUE CROSS OF ID
ID000010137639OtherREGENCE BLUE SHIELD OF ID
ID1371068Medicare ID - Type Unspecified
ID000010137639OtherREGENCE BLUE SHIELD OF ID