Provider Demographics
NPI:1316038607
Name:JOHNSON, ROGER T (PAC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PAC
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 1650
Mailing Address - Street 2:FAMILY HEALTHCARE ASSOC INC
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874
Mailing Address - Country:US
Mailing Address - Phone:304-732-6735
Mailing Address - Fax:304-732-9161
Practice Address - Street 1:MAIN ST
Practice Address - Street 2:FAMILY HEALTHCARE ASSOC INC
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874
Practice Address - Country:US
Practice Address - Phone:304-732-6735
Practice Address - Fax:304-732-9161
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000499Medicaid
WVP74423Medicare UPIN