Healthcare Provider Details

I. General information

NPI: 1053315028
Provider Name (Legal Business Name): WILLIAM WALTER JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 LAKELAND DR STE 900
JACKSON MS
39216-5028
US

IV. Provider business mailing address

536 ROYAL PECAN WAY
COLLIERVILLE TN
38017-1734
US

V. Phone/Fax

Practice location:
  • Phone: 601-840-1454
  • Fax:
Mailing address:
  • Phone: 662-538-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number14886
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number14886
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: