Provider Demographics
NPI:1699828400
Name:JOHNSON, STEPHEN CORNELIUS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CORNELIUS
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 1:4439 STATE ROUTE 159 STE 260
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7502
Mailing Address - Country:US
Mailing Address - Phone:740-779-4370
Mailing Address - Fax:740-779-4379
Practice Address - Street 1:4439 STATE ROUTE 159 STE 260
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7502
Practice Address - Country:US
Practice Address - Phone:740-779-4370
Practice Address - Fax:740-779-4379
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201215208800000X
OH35.095471208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3082775Medicaid