Provider Demographics
NPI:1285682179
Name:JOHNSON, DARRELL R (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:R
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:PO BOX 440100
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0100
Mailing Address - Country:US
Mailing Address - Phone:423-698-1844
Mailing Address - Fax:423-624-2226
Practice Address - Street 1:605 GLENWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1130
Practice Address - Country:US
Practice Address - Phone:423-698-1844
Practice Address - Fax:423-624-2226
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042297207RH0003X
TNMD23736207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00723841AMedicaid
TN3093100Medicaid
TNG07409Medicare UPIN
TN3093100Medicaid
TN3093101Medicare ID - Type UnspecifiedPROVIDER #