Provider Demographics
NPI:1124007851
Name:JOHNSON, CLYDE L JR (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:L
Last Name:JOHNSON
Suffix:JR
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 1:1051 JOHNSTON WILLIS DR.
Mailing Address - Street 2:ST. 200
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235
Mailing Address - Country:US
Mailing Address - Phone:804-320-2705
Mailing Address - Fax:804-330-2433
Practice Address - Street 1:1051 JOHNSTON WILLIS DR.
Practice Address - Street 2:ST. 200
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-320-2705
Practice Address - Fax:804-330-2433
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101223144208600000X
VA0101-223144208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7310871Medicaid
020001418Medicare ID - Type Unspecified
H13391Medicare UPIN