Provider Demographics
NPI:1699928432
Name:JOHNSON, GREG ANTHONY (CO, BOCP)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CO, BOCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 N PENELOPE LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7206
Mailing Address - Country:US
Mailing Address - Phone:479-305-9374
Mailing Address - Fax:
Practice Address - Street 1:1027 S MAIN ST STE LL3
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-4565
Practice Address - Country:US
Practice Address - Phone:417-726-9964
Practice Address - Fax:417-622-4449
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROP00095224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C51253OtherBOARD OF CERTIFICATION
CO004206OtherAMERICAN BOARD OF CERTIFICATION