Provider Demographics
NPI:1275591315
Name:JOHNSON, CLANCY HAGEDORN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLANCY
Middle Name:HAGEDORN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CLANCY
Other - Middle Name:JOHNSON
Other - Last Name:SINIPES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1300 BRIDGE CREEK DR. NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055
Mailing Address - Country:US
Mailing Address - Phone:256-737-7546
Mailing Address - Fax:256-841-6180
Practice Address - Street 1:1300 BRIDGE CREEK DR. NE
Practice Address - Street 2:SUITE A
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055
Practice Address - Country:US
Practice Address - Phone:256-737-7546
Practice Address - Fax:256-841-6180
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0027325207N00000X
AL00027325207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00390029OtherMEDICARE RAILROAD CARRIER PTAN
AL009937754Medicaid
AL051557589OtherBLUE CROSS BLUE SHIELD
ALCC9291OtherRAILROAD MEDICARE
AL009937754Medicaid
ALI52978Medicare UPIN