Provider Demographics
NPI:1053315028
Name:JOHNSON, WILLIAM WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTER
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 1:536 ROYAL PECAN WAY
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-1734
Mailing Address - Country:US
Mailing Address - Phone:662-538-8009
Mailing Address - Fax:
Practice Address - Street 1:1935 LAKELAND DR STE 900
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5028
Practice Address - Country:US
Practice Address - Phone:601-840-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14886207V00000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015923Medicaid
MS743030196OtherPRACTICE TAX ID #
MS00117218Medicaid
MS160000321Medicare ID - Type Unspecified
MS09015923Medicaid