Provider Demographics
NPI:1801454244
Name:JOHNSON, OLIVIA (MD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
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 1:864 BLACK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FOUR OAKS
Mailing Address - State:NC
Mailing Address - Zip Code:27524-8314
Mailing Address - Country:US
Mailing Address - Phone:919-936-3148
Mailing Address - Fax:919-936-2900
Practice Address - Street 1:864 BLACK CREEK RD
Practice Address - Street 2:
Practice Address - City:FOUR OAKS
Practice Address - State:NC
Practice Address - Zip Code:27524-8314
Practice Address - Country:US
Practice Address - Phone:919-936-3148
Practice Address - Fax:919-936-2900
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09933207Q00000X
390200000X
NC202302334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program