Provider Demographics
NPI:1700908670
Name:JOHNSON, CARL ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:ALLEN
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 1:2610 BLOSSOM ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2308
Mailing Address - Country:US
Mailing Address - Phone:805-740-1317
Mailing Address - Fax:
Practice Address - Street 1:2610 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2308
Practice Address - Country:US
Practice Address - Phone:805-740-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11965207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology