Provider Demographics
NPI:1922473966
Name:JOHNSON, OBIE S (BA)
Entity Type:Individual
Prefix:MR
First Name:OBIE
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 LAURA DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2988
Mailing Address - Country:US
Mailing Address - Phone:985-446-4114
Mailing Address - Fax:985-446-4112
Practice Address - Street 1:142 LAURA DR
Practice Address - Street 2:SUITE D
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2988
Practice Address - Country:US
Practice Address - Phone:985-446-4114
Practice Address - Fax:985-446-4112
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker