Basic Information
| Provider Information | |||||||||
| NPI: | 1174692248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14883 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274154883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362743241 | ||||||||
| FaxNumber: | 3362727134 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362743241 | ||||||||
| FaxNumber: | 3362747134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 04/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 21573 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1113 | 01 | NC | PARTNERS MEDICARE | OTHER | 26035 | 01 | NC | MEDCOST | OTHER | 46432 | 01 | NC | BCBS OF NC | OTHER | 8946432 | 05 | NC | MEDICAID |