Provider Demographics
NPI:1649375064
Name:JOHNSON, CHARLES (M D)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:MRS
Other - First Name:VICKI
Other - Middle Name:
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EXECUTIVE
Mailing Address - Street 1:1209 E POINTE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-9488
Mailing Address - Country:US
Mailing Address - Phone:919-620-9107
Mailing Address - Fax:
Practice Address - Street 1:1003 12TH ST
Practice Address - Street 2:
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509-1626
Practice Address - Country:US
Practice Address - Phone:919-575-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14695207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC00110Medicare UPIN