Provider Demographics
NPI:1942511456
Name:JOHNSON, AMANDA BETH (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4944
Mailing Address - Country:US
Mailing Address - Phone:850-873-3990
Mailing Address - Fax:850-215-0469
Practice Address - Street 1:140 BURKE CALHOUN CITY RD
Practice Address - Street 2:
Practice Address - City:CALHOUN CITY
Practice Address - State:MS
Practice Address - Zip Code:38916-9690
Practice Address - Country:US
Practice Address - Phone:662-628-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS152692085R0202X, 2085R0204X
MS264272085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFY7AZOtherFL BLUE PROVIDER NUMBER
MS04385321Medicaid