Provider Demographics
NPI:1992798375
Name:JOHNSON, MICHAEL SCOTT (CPO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 NORTH COLLEGE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3382
Mailing Address - Country:US
Mailing Address - Phone:208-733-0505
Mailing Address - Fax:208-734-0766
Practice Address - Street 1:762 NORTH COLLEGE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3382
Practice Address - Country:US
Practice Address - Phone:208-733-0505
Practice Address - Fax:208-734-0766
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID4904330001Medicare ID - Type Unspecified