Provider Demographics
NPI:1700853058
Name:JOHNSON, STEVEN WAYNE (DO)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 OAK CLUSTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862
Mailing Address - Country:US
Mailing Address - Phone:865-908-3636
Mailing Address - Fax:865-908-3632
Practice Address - Street 1:1105 OAK CLUSTER DRIVE
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862
Practice Address - Country:US
Practice Address - Phone:865-908-3636
Practice Address - Fax:865-908-3632
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTNDO0000001152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46032Medicare UPIN
3720457Medicare ID - Type Unspecified