Healthcare Provider Details

I. General information

NPI: 1902812803
Provider Name (Legal Business Name): ERIC CHARLES JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 PROVIDENCE PARK DRIVE E STE 102
MOBILE AL
36695-4618
US

IV. Provider business mailing address

610 PROVIDENCE PARK DRIVE E STE 102
MOBILE AL
36695-4618
US

V. Phone/Fax

Practice location:
  • Phone: 251-639-5070
  • Fax: 251-634-2994
Mailing address:
  • Phone: 251-639-5070
  • Fax: 251-634-2994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00014861
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: