Provider Demographics
NPI:1609923416
Name:JOHNSON, JAMES GOWEN IV (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GOWEN
Last Name:JOHNSON
Suffix:IV
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:STE 520
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4291
Practice Address - Country:US
Practice Address - Phone:864-455-9033
Practice Address - Fax:864-455-6559
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35446207RI0200X, 207RI0200X
TN44275207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAPPROVEDMedicaid
SCAPPROVEDMedicare PIN