Provider Demographics
NPI:1790705796
Name:JOHNSON, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:4237 RIVER HILLS DR
Practice Address - Street 2:STE 130
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6444
Practice Address - Country:US
Practice Address - Phone:843-234-8675
Practice Address - Fax:843-234-8681
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200000236207R00000X
SC35605207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00236Medicaid