Provider Demographics
NPI:1083889364
Name:JOHNSON, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
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 1:205 SAGE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-6995
Mailing Address - Country:US
Mailing Address - Phone:919-942-4173
Mailing Address - Fax:
Practice Address - Street 1:205 SAGE RD
Practice Address - Street 2:SUITE #100
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-6995
Practice Address - Country:US
Practice Address - Phone:919-942-4173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00553208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910399Medicaid