Provider Demographics
NPI:1497757603
Name:JOHNSON, SIDNEY A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:A
Last Name:JOHNSON
Suffix:JR
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 4997
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4997
Mailing Address - Country:US
Mailing Address - Phone:601-362-0600
Mailing Address - Fax:
Practice Address - Street 1:2969 CURRAN DR N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4121
Practice Address - Country:US
Practice Address - Phone:601-200-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS107042085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1497757603OtherNPI
LA1961809Medicaid
MS000015534Medicaid
MS0015534Medicaid
E10311Medicare UPIN
920001071Medicare ID - Type Unspecified
LA1961809Medicaid