Basic Information
| Provider Information | |||||||||
| NPI: | 1811974926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3310 WEST END AVE 590 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159135086 | ||||||||
| FaxNumber: | 8884942588 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 OAKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374162367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238924289 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 049908 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0102830 | 01 | GA | UNITED HEALTHCARE | OTHER | 841074 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 000905121C | 01 | GA | MEDICAID GA | OTHER | 89064FN | 01 | NC | MEDICAID NC | OTHER | P00048268 | 01 | GA | RAILROAD MEDICARE | OTHER |