Provider Demographics
NPI:1962738500
Name:JOHNSON, EDDIE GLEN III (MD)
Entity type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:GLEN
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 GRAYSON CIR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-8605
Mailing Address - Country:US
Mailing Address - Phone:318-458-2756
Mailing Address - Fax:
Practice Address - Street 1:7330 FERN AVE STE 1103
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4989
Practice Address - Country:US
Practice Address - Phone:318-798-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-01
Last Update Date:2009-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013312208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice