Basic Information
| Provider Information | |||||||||
| NPI: | 1649273509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | VERONICA | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2106 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393022106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017034597 | ||||||||
| Practice Location | |||||||||
| Address1: | 252 NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393459756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016833117 | ||||||||
| FaxNumber: | 6016832505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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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 | 207R00000X | 16109 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00119950 | 05 | MS | MEDICAID |