Healthcare Provider Details

I. General information

NPI: 1750395356
Provider Name (Legal Business Name): STEPHEN JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 JEFFERSON ST
LAUREL MS
39440-4354
US

IV. Provider business mailing address

1203 JEFFERSON ST
LAUREL MS
39440-4354
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-2863
  • Fax: 601-649-9479
Mailing address:
  • Phone: 601-649-2863
  • Fax: 601-649-9479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number13106
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: