Provider Demographics
NPI:1528261872
Name:M COLE JOHNSON, INC
Entity type:Organization
Organization Name:M COLE JOHNSON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYBEN
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-733-1112
Mailing Address - Street 1:526 SHOUP AVE W
Mailing Address - Street 2:SUITE E
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5050
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:SUITE E
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-733-1112
Practice Address - Fax:208-732-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010137639OtherBLUESHIELD
IDS3788OtherBLUECROSS
ID000010137639OtherBLUESHIELD
ID1372573Medicare ID - Type UnspecifiedMEDICARE-INDIVIDUAL
IDS3788OtherBLUECROSS