Provider Demographics
NPI:1295325033
Name:JOHNSON, MITCHELL LAMAR
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:LAMAR
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 3250
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-3250
Mailing Address - Country:US
Mailing Address - Phone:601-559-0185
Mailing Address - Fax:
Practice Address - Street 1:10176 WELDWOOD DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-9368
Practice Address - Country:US
Practice Address - Phone:160-155-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800098410172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800098410OtherDRIVER LICENSE