Healthcare Provider Details

I. General information

NPI: 1902095664
Provider Name (Legal Business Name): DARYL AUNDRA JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-579-5459
  • Fax: 601-268-5733
Mailing address:
  • Phone: 601-579-5459
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberT-2057
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberT-2057
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number23216
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: