Provider Demographics
NPI:1053945352
Name:JOHNSON, ROBERT LEROY
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEROY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TUCKER RD.
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542
Mailing Address - Country:US
Mailing Address - Phone:870-955-0972
Mailing Address - Fax:
Practice Address - Street 1:29 TUCKER RD
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:AR
Practice Address - Zip Code:72542-9115
Practice Address - Country:US
Practice Address - Phone:870-955-0972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider