Provider Demographics
NPI:1467751495
Name:DR. TERRY D. JOHNSON, P.A.
Entity Type:Organization
Organization Name:DR. TERRY D. JOHNSON, P.A.
Other - Org Name:FORESTVIEW PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-590-6561
Mailing Address - Street 1:PO BOX 17190
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-7190
Mailing Address - Country:US
Mailing Address - Phone:702-560-2916
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:511 N HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3132
Practice Address - Country:US
Practice Address - Phone:843-761-0936
Practice Address - Fax:843-761-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5644Medicaid
SC9903Medicare PIN