Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 3154 | AR |
Y | 213EG0000X | General Practice | 3154 | AR |
NPI | 1003910159 |
---|---|
Provider Name | Mr. Carl Briner Johnston |
First Address | Crossett, AR 71635 |
Second Address | Crossett, AR 71635 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
59970 | BCBS (01) | AR |
704630 | UNITED CONCORDIA (01) | AR |