Provider Demographics
NPI:1669489639
Name:JOHNSON, BEVERLY CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:CLARK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 ANDREW JACKSON DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1723
Mailing Address - Country:US
Mailing Address - Phone:931-980-5375
Mailing Address - Fax:
Practice Address - Street 1:272 ANDREW JACKSON DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-1723
Practice Address - Country:US
Practice Address - Phone:931-980-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD28806207Q00000X
KY35099208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64350994Medicaid
TN3811144Medicaid
TN3811144Medicaid