Provider Demographics
NPI:1619081346
Name:JOHNSON, RICHARD SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
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 16076
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-6076
Mailing Address - Country:US
Mailing Address - Phone:601-982-6001
Mailing Address - Fax:601-982-8616
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-982-6001
Practice Address - Fax:601-982-8616
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18112207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01886827Medicaid
MSH97086Medicare UPIN