Provider Demographics
NPI:1811512494
Name:JOHNSON, MATTHEW B (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-1701
Mailing Address - Country:US
Mailing Address - Phone:606-573-4520
Mailing Address - Fax:606-573-6392
Practice Address - Street 1:37 BALL PARK RD
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-1701
Practice Address - Country:US
Practice Address - Phone:606-573-4520
Practice Address - Fax:606-573-6392
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116034070207R00000X
KY05495207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine