Provider Demographics
NPI:1821197609
Name:JOHNSON, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
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 1:306 MEDICAL PARK CT
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4346
Mailing Address - Country:US
Mailing Address - Phone:252-247-2101
Mailing Address - Fax:252-247-4675
Practice Address - Street 1:306 MEDICAL PARK CT
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4346
Practice Address - Country:US
Practice Address - Phone:252-247-2101
Practice Address - Fax:252-247-4675
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300816208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134V5Medicaid
NC89134V5Medicaid
NCH92029Medicare UPIN