Provider Demographics
NPI:1477578110
Name:JOHNSON, ERNEST VAN (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:VAN
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 1:535 JACK WARNER PKWY NE
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-5751
Mailing Address - Country:US
Mailing Address - Phone:205-556-2121
Mailing Address - Fax:205-554-0152
Practice Address - Street 1:535 JACK WARNER PKWY NE
Practice Address - Street 2:SUITE B-1
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5751
Practice Address - Country:US
Practice Address - Phone:205-556-2121
Practice Address - Fax:205-554-0152
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11457174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529202430Medicaid
AL84660Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO
ALC70162Medicare UPIN