Provider Demographics
NPI:1083638217
Name:JOHNSON, SAMUEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
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 1:600 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3014
Mailing Address - Country:US
Mailing Address - Phone:662-327-7525
Mailing Address - Fax:662-243-2252
Practice Address - Street 1:600 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3014
Practice Address - Country:US
Practice Address - Phone:662-327-7525
Practice Address - Fax:662-243-2252
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS730-06661OtherBLUE CROSS OF ALABAMA
MS00114403Medicaid
MS009914955OtherALACAID
MS640813832OtherTAX ID
MS100015721OtherRAILROAD MEDICARE
MS100000142Medicare ID - Type Unspecified
MS100015721OtherRAILROAD MEDICARE