Basic Information
| Provider Information | |||||||||
| NPI: | 1922003318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 460 | ||||||||
| Address2: | |||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249860460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 3045365031 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 MALLARD COURT | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258013140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042550800 | ||||||||
| FaxNumber: | 3042551040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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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 | 208000000X | 20381 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3002516001 | 05 | WV | MEDICAID | 562370581001 | 01 | WV | BSMT-WV | OTHER | 010056306 | 05 | VA | MEDICAID | 562370581 | 01 | WV | UMWA | OTHER | 7663338 | 01 | WV | AETNA | OTHER | 141518 | 01 | WV | CARELINK | OTHER |