Provider Demographics
NPI:1295882348
Name:JOHNSON, DAVID WESLEY (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WESLEY
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:PO BOX 30459
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0008
Mailing Address - Country:US
Mailing Address - Phone:931-245-1150
Mailing Address - Fax:931-245-0605
Practice Address - Street 1:251 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5086
Practice Address - Country:US
Practice Address - Phone:931-245-1150
Practice Address - Fax:931-245-0605
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26547207Q00000X
TN53885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022939Medicaid