Provider Demographics
NPI:1700884046
Name:JOHNSON, ADEYEMI S (MD)
Entity Type:Individual
Prefix:
First Name:ADEYEMI
Middle Name:S
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 1:1718 E 4TH ST
Mailing Address - Street 2:STE 501
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3260
Mailing Address - Country:US
Mailing Address - Phone:704-343-9800
Mailing Address - Fax:704-887-7570
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:STE 501
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3260
Practice Address - Country:US
Practice Address - Phone:704-343-9800
Practice Address - Fax:704-887-7570
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35671207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8946421Medicaid
SCN35671Medicaid
E20478Medicare UPIN
NC2174572BMedicare PIN