Provider Demographics
NPI:1720308851
Name:JOHNSON, DOMINIC ADRIAN (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:ADRIAN
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 1:877 W FARIS RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4296
Mailing Address - Country:US
Mailing Address - Phone:864-455-6993
Mailing Address - Fax:
Practice Address - Street 1:1005 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4630
Practice Address - Country:US
Practice Address - Phone:864-455-6900
Practice Address - Fax:864-255-5619
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37108207RC0000X, 207R00000X, 207RI0011X
SCMD37108207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC62139223Medicare PIN