Provider Demographics
NPI:1750342879
Name:JOHNSON, CLANFORD LYONEL (MD)
Entity type:Individual
Prefix:
First Name:CLANFORD
Middle Name:LYONEL
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:1305 S SUBER RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-0944
Practice Address - Country:US
Practice Address - Phone:864-989-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400688207Q00000X
SC25112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904663Medicaid
NCP00329935OtherRAILROAD MEDICARE
NC5904663Medicaid
NC2034890BMedicare PIN
NC3806171OtherCIGNA HEALTHCARE
NCI21317Medicare UPIN
NC191230OtherMEDCOST