Provider Demographics
NPI:1780667501
Name:JOHNSON, STEPHEN E (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
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 1:6602 KNIGHTDALE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6525
Mailing Address - Country:US
Mailing Address - Phone:919-747-5210
Mailing Address - Fax:919-747-5211
Practice Address - Street 1:6602 KNIGHTDALE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6525
Practice Address - Country:US
Practice Address - Phone:919-747-5210
Practice Address - Fax:919-747-5211
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42431207P00000X
NC21409207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45904324Medicaid
COC84751Medicare UPIN
CO45904324Medicaid