Provider Demographics
NPI:1982650289
Name:JOHNSON, BRUCE DEWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DEWAYNE
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 1:1092 SUGARHILL PL
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4538
Mailing Address - Country:US
Mailing Address - Phone:931-261-7399
Mailing Address - Fax:
Practice Address - Street 1:142 W 5TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1760
Practice Address - Country:US
Practice Address - Phone:931-528-2541
Practice Address - Fax:530-243-0445
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000040859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3338289Medicaid
TN3338289Medicare PIN