Healthcare Provider Details

I. General information

NPI: 1417028762
Provider Name (Legal Business Name): JOHN R. JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 BRYAN BLVD
CORBIN KY
40701-2788
US

IV. Provider business mailing address

PO BOX 950248
LOUISVILLE KY
40295-0248
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-4590
  • Fax: 606-526-0548
Mailing address:
  • Phone: 502-489-5730
  • Fax: 502-489-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number21412
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21412
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: