Provider Demographics
NPI:1083655161
Name:JOHNSON, THERESA M
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 JOHN PLATT DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4321
Mailing Address - Country:US
Mailing Address - Phone:252-247-4297
Mailing Address - Fax:252-247-7383
Practice Address - Street 1:3511 JOHN PLATT DR
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4321
Practice Address - Country:US
Practice Address - Phone:252-247-4297
Practice Address - Fax:252-247-7383
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301023207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901347Medicaid
NC2038979Medicare ID - Type UnspecifiedMEDICARE
NC5901347Medicaid