Basic Information
| Provider Information | |||||||||
| NPI: | 1083655161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3511 JOHN PLATT DR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522474297 | ||||||||
| FaxNumber: | 2522477383 | ||||||||
| Practice Location | |||||||||
| Address1: | 3511 JOHN PLATT DR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522474297 | ||||||||
| FaxNumber: | 2522477383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 200301023 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 5901347 | 05 | NC | MEDICAID |