Provider Demographics
NPI:1386631729
Name:JOHNSON, MARY HEATHER (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HEATHER
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 1:3103 BUSINESS PARK CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3676
Mailing Address - Country:US
Mailing Address - Phone:615-851-7865
Mailing Address - Fax:615-851-7853
Practice Address - Street 1:3103 BUSINESS PARK CIR STE 100
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3676
Practice Address - Country:US
Practice Address - Phone:615-851-7865
Practice Address - Fax:615-851-7853
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD29117208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
8806699003OtherCIGNA HMO
949814OtherAETNA
TN3898510Medicaid
8806699002OtherCIGNA COMM
1240316OtherUNITED HEALTHCARE HMO
TN3146836OtherBLUE CROSS
8806699002OtherCIGNA COMM