Provider Demographics
NPI:1134142334
Name:JOHNSON, MATHEW BOWEN JR (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:BOWEN
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 1:703 ALCORN DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9302
Mailing Address - Country:US
Mailing Address - Phone:662-286-2522
Mailing Address - Fax:662-293-4288
Practice Address - Street 1:703 ALCORN DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9302
Practice Address - Country:US
Practice Address - Phone:662-286-2522
Practice Address - Fax:662-293-4288
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15536208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122266Medicaid
MS00122266Medicaid
H13778Medicare UPIN