Provider Demographics
NPI:1457304131
Name:JOHNSON, SAMUEL T SR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:T
Last Name:JOHNSON
Suffix:SR
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:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-0507
Mailing Address - Country:US
Mailing Address - Phone:901-475-4752
Mailing Address - Fax:901-475-1554
Practice Address - Street 1:4235 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:TN
Practice Address - Zip Code:38011-6921
Practice Address - Country:US
Practice Address - Phone:901-475-4752
Practice Address - Fax:901-475-1554
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3718265Medicaid
141592OtherBETTER HEALTH UNISON
TN268267OtherUNISON ADVANTAGE
TN4309182OtherBCBSTN INDIVIDUAL
TN3017954OtherCIGNA
TN27017OtherTLC
TN1525754Medicaid
TN4063363OtherBCROSS
TN4229920OtherBCBSTN
TN4909218OtherBCBCTN GROUP
TN30179512Medicare PIN
TN4909218OtherBCBCTN GROUP
TN3017954OtherCIGNA
TN27017OtherTLC