Provider Demographics
NPI:1073578456
Name:JOHNSON, AMY E (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-422-0213
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:2863 HIGHWAY 45 BYP
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3618
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-660-8369
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49323208000000X
CODR.0049323207PP0204X
TNINPROCESS208000000X
TNMD63332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000619523Medicaid
GA000619523Medicaid
GAS87766Medicare UPIN