Provider Demographics
NPI:1356474662
Name:JOHNSON, LIVETTE (MD)
Entity Type:Individual
Prefix:
First Name:LIVETTE
Middle Name:
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 1:1005 DR DB TODD JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3501
Mailing Address - Country:US
Mailing Address - Phone:615-327-5572
Mailing Address - Fax:615-327-5555
Practice Address - Street 1:1005 DR DB TODD JR BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3501
Practice Address - Country:US
Practice Address - Phone:615-327-5572
Practice Address - Fax:615-327-5555
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54474207RI0200X
NY189885207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01621094Medicaid
NY017J09Medicare ID - Type Unspecified
NYF98803Medicare UPIN