Provider Demographics
NPI:1902860372
Name:JOHNSON, JOHN ALDEN III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALDEN
Last Name:JOHNSON
Suffix:III
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5660
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5660
Practice Address - Fax:601-268-5759
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4429208600000X
MS12130208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4344773OtherCIGNA
MS6027328OtherHEALTHSPRINGS
MS04431870Medicaid
AR123146001Medicaid
MS4594666OtherAETNA
AR123146001Medicaid
MS4594666OtherAETNA
E38111Medicare UPIN