Basic Information
| Provider Information | |||||||||
| NPI: | 1700884046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ADEYEMI | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1718 E 4TH ST | ||||||||
| Address2: | STE 501 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043439800 | ||||||||
| FaxNumber: | 7048877570 | ||||||||
| Practice Location | |||||||||
| Address1: | 1718 E 4TH ST | ||||||||
| Address2: | STE 501 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043439800 | ||||||||
| FaxNumber: | 7048877570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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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 | 207RC0000X | 35671 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 8946421 | 05 | NC | MEDICAID | N35671 | 05 | SC | MEDICAID |