Provider Demographics
NPI:1033137146
Name:JOHNSON, CHARLES PATRICK (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1751 GUNBARREL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7177
Mailing Address - Country:US
Mailing Address - Phone:423-778-8558
Mailing Address - Fax:423-778-8560
Practice Address - Street 1:1751 GUNBARREL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7177
Practice Address - Country:US
Practice Address - Phone:423-778-8558
Practice Address - Fax:423-778-8560
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000000469207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C48483Medicare UPIN
3302293Medicare ID - Type Unspecified