Provider Demographics
NPI:1285683342
Name:JOHNSON, JUANTINA MECHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUANTINA
Middle Name:MECHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 HOSPITAL CIR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:MS
Mailing Address - Zip Code:39350-6781
Mailing Address - Country:US
Mailing Address - Phone:601-389-6302
Mailing Address - Fax:601-663-7924
Practice Address - Street 1:210 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6781
Practice Address - Country:US
Practice Address - Phone:601-389-6302
Practice Address - Fax:601-663-7924
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD026588207PE0004X
MS21445207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01504386Medicaid
PATEZ312RFIMedicare PIN
MS01504386Medicaid
PATEZ312RFHMedicare PIN
PATEZ312RFFMedicare PIN