Provider Demographics
NPI:1285683649
Name:JOHNSON, BOBBY (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
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 1:201 SIVLEY RD
Mailing Address - Street 2:STE 450
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-551-4505
Mailing Address - Fax:
Practice Address - Street 1:201 SIVLEY RD
Practice Address - Street 2:STE 450
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-551-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10873207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51078423OtherBCBS
AL000078423Medicaid
C73532Medicare UPIN
000078423Medicare ID - Type Unspecified