Provider Demographics
NPI:1316232325
Name:JOHNSON, ZACH (DO)
Entity type:Individual
Prefix:
First Name:ZACH
Middle Name:
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 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-221-5250
Mailing Address - Fax:573-231-3824
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-221-5250
Practice Address - Fax:573-231-3824
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015029479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics