Healthcare Provider Details

I. General information

NPI: 1497757603
Provider Name (Legal Business Name): SIDNEY A JOHNSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2969 CURRAN DR N
JACKSON MS
39216-4121
US

IV. Provider business mailing address

PO BOX 4997
JACKSON MS
39296-4997
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-3070
  • Fax:
Mailing address:
  • Phone: 601-362-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number10704
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: