Provider Demographics
NPI:1548379381
Name:JOHNSON, TERRY A (DO)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9757
Mailing Address - Country:US
Mailing Address - Phone:740-289-2371
Mailing Address - Fax:740-289-4291
Practice Address - Street 1:715 W EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1015
Practice Address - Country:US
Practice Address - Phone:740-947-8777
Practice Address - Fax:740-947-7728
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0933593Medicaid
OH0742845Medicare ID - Type Unspecified
OHF60828Medicare UPIN