Provider Demographics
NPI:1750375598
Name:JOHNSON, CYNDA ANN (MD MBA)
Entity type:Individual
Prefix:MRS
First Name:CYNDA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 SOUTH CHARLES BLVD
Mailing Address - Street 2:GREENVILLE CENTRE ROOM 1515
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4353
Mailing Address - Country:US
Mailing Address - Phone:252-328-9478
Mailing Address - Fax:252-328-2769
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:FAMILY PRACTICE CENTER
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-4611
Practice Address - Fax:252-744-4614
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-05-30
Deactivation Date:2006-06-14
Deactivation Code:
Reactivation Date:2007-02-06
Provider Licenses
StateLicense IDTaxonomies
NC200400689207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1375NOtherBCBS NC
NC891375NMedicaid
NCE22821Medicare UPIN
NC2033855Medicare ID - Type Unspecified