Provider Demographics
NPI:1235238171
Name:JOHNSON, SALLY R (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7011 FAYETTEVILLE RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7745
Practice Address - Country:US
Practice Address - Phone:919-361-2644
Practice Address - Fax:919-484-0849
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132RGMedicaid
NCH68650Medicare UPIN
NC2007106Medicare ID - Type Unspecified