1134191158 NPI number — NORMAN C JOHNSON OD

Table of content: NORMAN C JOHNSON OD (NPI 1134191158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134191158 NPI number — NORMAN C JOHNSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
NORMAN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1134191158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15933 CLAYTON RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
828 S BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBORO
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35768-2508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-259-4119
Provider Business Practice Location Address Fax Number:
256-259-3643
Provider Enumeration Date:
02/03/2006

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: 152W00000X , with the licence number:  S464TA172 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 051513019 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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