Provider Demographics
NPI:1982991220
Name:JOHNSON, CASEY B (MD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:B
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 1:1519 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-5401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 W LAKESHORE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-0500
Practice Address - Country:US
Practice Address - Phone:205-930-2950
Practice Address - Fax:205-930-2957
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL34237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51168738OtherBLUE CROSS-280
AL51170919OtherBLUE CROSS TRUSSVILLE
AL51168737OtherBLUE CROSS BLUE SHIELD