Provider Demographics
NPI:1396205134
Name:JOHNSON, NICHOLAS EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:EDWIN
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 1:598 GEIGER BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29904
Mailing Address - Country:US
Mailing Address - Phone:727-599-4414
Mailing Address - Fax:
Practice Address - Street 1:598 GEIGER BLVD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29904
Practice Address - Country:US
Practice Address - Phone:727-599-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
FLME146398208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider