Provider Demographics
NPI:1457644254
Name:JOHNSON, MEGAN D
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 W ELK AVE
Mailing Address - Street 2:SUITE 21
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2895
Mailing Address - Country:US
Mailing Address - Phone:423-542-7420
Mailing Address - Fax:423-542-7425
Practice Address - Street 1:1497 W ELK AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2895
Practice Address - Country:US
Practice Address - Phone:423-542-7420
Practice Address - Fax:423-542-7425
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457644254Medicaid
TN6023539OtherBLUECARE
TNQ008037Medicaid
TN6023539OtherBLUECARE