Provider Demographics
NPI:1265851919
Name:JOHNSON, DONTAL (MD)
Entity Type:Individual
Prefix:
First Name:DONTAL
Middle Name:
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 1:944 21ST AVE N APT 1015
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3448
Mailing Address - Country:US
Mailing Address - Phone:214-684-0906
Mailing Address - Fax:
Practice Address - Street 1:2200 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0005
Practice Address - Country:US
Practice Address - Phone:615-936-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN55725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program