Provider Demographics
NPI:1568751345
Name:JOHNSON, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
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:PO BOX 1000
Mailing Address - Street 2:DEPT 978
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-320-6915
Mailing Address - Fax:901-320-6920
Practice Address - Street 1:3473 POPLAR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4654
Practice Address - Country:US
Practice Address - Phone:901-320-6915
Practice Address - Fax:901-320-6920
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54615207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121526Medicaid