1609923416 NPI number — JAMES GOWEN JOHNSON IV MD

Table of content: ANNETTE E LARA (NPI 1598432353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609923416 NPI number — JAMES GOWEN JOHNSON IV MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
JAMES
Provider Middle Name:
GOWEN
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609923416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 INDEPENDENCE PT
Provider Second Line Business Mailing Address:
STE 212
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 W FARIS RD
Provider Second Line Business Practice Location Address:
STE 520
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-4291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-455-9033
Provider Business Practice Location Address Fax Number:
864-455-6559
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  35446 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: APPROVED , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com