Provider Demographics
NPI:1043387459
Name:JOHNSON, BURT POWERS (MD)
Entity Type:Individual
Prefix:DR
First Name:BURT
Middle Name:POWERS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 CREEKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7656
Mailing Address - Country:US
Mailing Address - Phone:910-681-1161
Mailing Address - Fax:910-251-6511
Practice Address - Street 1:2023 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6600
Practice Address - Country:US
Practice Address - Phone:910-251-6499
Practice Address - Fax:910-251-6511
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC204082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136KHMedicaid
NC136KHOtherBLUE CROSS NORTH CAROLINA
NC2022617Medicare ID - Type Unspecified
NC89136KHMedicaid