Provider Demographics
NPI:1275594079
Name:JOHNSON, EARLIE T JR (MD)
Entity Type:Individual
Prefix:MR
First Name:EARLIE
Middle Name:T
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7420
Mailing Address - Country:US
Mailing Address - Phone:910-347-1673
Mailing Address - Fax:
Practice Address - Street 1:2580 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5252
Practice Address - Country:US
Practice Address - Phone:910-346-1188
Practice Address - Fax:910-346-1275
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0154HOtherBCBS
NC890154HMedicaid
NC890154HMedicaid
NC0154HOtherBCBS