Provider Demographics
NPI:1467487686
Name:JOHNSON, RONALD LEE SR (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:LEE
Last Name:JOHNSON
Suffix:SR
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 1:4100 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5800
Mailing Address - Country:US
Mailing Address - Phone:803-786-0980
Mailing Address - Fax:803-786-6452
Practice Address - Street 1:4100 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-786-0980
Practice Address - Fax:803-786-6452
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10556207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAT1078Medicaid
SCD176390281Medicare PIN
SCAT1078Medicaid