Provider Demographics
NPI:1760459440
Name:JOHNSON, JEFF (MD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
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 1:1903 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7105
Mailing Address - Country:US
Mailing Address - Phone:270-442-1671
Mailing Address - Fax:270-442-7307
Practice Address - Street 1:1903 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7105
Practice Address - Country:US
Practice Address - Phone:270-442-1671
Practice Address - Fax:270-442-7307
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15239207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000044966OtherANTHEM BCBS
KY64152390Medicaid
IL0040162029Medicaid
000000044966OtherANTHEM BCBS
0544001Medicare PIN