Provider Demographics
NPI:1528266517
Name:STEPHEN M JOHNSON MD PC
Entity type:Organization
Organization Name:STEPHEN M JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHATLOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-817-1762
Mailing Address - Street 1:200 W 103RD ST
Mailing Address - Street 2:STE 1000
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1092
Mailing Address - Country:US
Mailing Address - Phone:317-817-1765
Mailing Address - Fax:317-817-1767
Practice Address - Street 1:200 W 103RD ST
Practice Address - Street 2:STE 1000
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1092
Practice Address - Country:US
Practice Address - Phone:317-817-1765
Practice Address - Fax:317-817-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027083207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100072660AMedicaid
INE06470Medicare UPIN
IN100072660AMedicaid