Healthcare Provider Details

I. General information

NPI: 1184610461
Provider Name (Legal Business Name): STAN MICHAEL JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 CASSIDY BLVD
PIKEVILLE KY
41501-1426
US

IV. Provider business mailing address

PO BOX 432
PIKEVILLE KY
41502-0432
US

V. Phone/Fax

Practice location:
  • Phone: 606-430-2230
  • Fax: 606-437-2526
Mailing address:
  • Phone: 606-430-3500
  • Fax: 606-437-2526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39306
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: