Provider Demographics
NPI:1265760482
Name:JOHNSON, GEORGE REGINALD
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:REGINALD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39215-1939
Mailing Address - Country:US
Mailing Address - Phone:601-672-9685
Mailing Address - Fax:601-815-9804
Practice Address - Street 1:194 MIDWAY ESTATES DR
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170-8488
Practice Address - Country:US
Practice Address - Phone:601-878-0487
Practice Address - Fax:601-815-9804
Is Sole Proprietor?:No
Enumeration Date:2009-11-29
Last Update Date:2009-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor