Provider Demographics
NPI:1174634661
Name:JOHNSON, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
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 1:4678 ZEBULON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3511
Mailing Address - Country:US
Mailing Address - Phone:606-432-3066
Mailing Address - Fax:
Practice Address - Street 1:911 BYPASS RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-218-4506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64144686Medicaid
C68751Medicare UPIN
KY64144686Medicaid