Basic Information
| Provider Information | |||||||||
| NPI: | 1316987043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1490 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286071490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282623886 | ||||||||
| FaxNumber: | 8282654816 | ||||||||
| Practice Location | |||||||||
| Address1: | 2659 US HWY 70 EAST | ||||||||
| Address2: | |||||||||
| City: | VALDESE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285804080 | ||||||||
| FaxNumber: | 8285804089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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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 | 207Q00000X | 9400856 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | AJ9529756 | 01 | NC | DEA | OTHER | 8946028 | 05 | NC | MEDICAID |