Provider Demographics
NPI:1033461009
Name:JUANTINA JOHNSON MD LLC
Entity Type:Organization
Organization Name:JUANTINA JOHNSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-953-4864
Mailing Address - Street 1:757 BURTON CLARK RD
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:MS
Mailing Address - Zip Code:39328-6145
Mailing Address - Country:US
Mailing Address - Phone:877-953-4864
Mailing Address - Fax:770-953-8132
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:877-953-4864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21445207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty