Provider Demographics
NPI:1821096421
Name:JOHNSON, THOMAS DWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DWAYNE
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1417 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:KY
Practice Address - Zip Code:42629-2411
Practice Address - Country:US
Practice Address - Phone:270-343-2597
Practice Address - Fax:270-343-2598
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37317208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000294096OtherANTHEM BC/BS
KY000000294096OtherANTHEM BC/BS
0557004Medicare ID - Type Unspecified