Provider Demographics
NPI:1750606075
Name:JOHNSON, SUSANNAH E (MD)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-638-4023
Mailing Address - Fax:252-633-2833
Practice Address - Street 1:2604 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4238
Practice Address - Country:US
Practice Address - Phone:252-638-4023
Practice Address - Fax:252-633-2833
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50503207R00000X, 208M00000X
NC2021-01038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100265170Medicaid
TNQ001805Medicaid
TN6002116OtherBLUECROSS BLUESHIELD
TN6010882OtherBLUE CROSS-BLUE SHIELD
TN103I111063Medicare PIN
TN103I111249Medicare PIN