Basic Information
| Provider Information | |||||||||
| NPI: | 1154365583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 W CLINCH AVE | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655241631 | ||||||||
| FaxNumber: | 8655411727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18815 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3033627 | 05 | TN | MEDICAID | 080064816 | 01 | TN | RR MEDICARE PIN | OTHER |