Healthcare Provider Details

I. General information

NPI: 1225087588
Provider Name (Legal Business Name): WAYNE C JOHNSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HIGHWAY 49 S STE 4
RICHLAND MS
39218-9425
US

IV. Provider business mailing address

PO BOX 321359
FLOWOOD MS
39232-1359
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-6400
  • Fax: 601-932-6437
Mailing address:
  • Phone: 601-936-1395
  • Fax: 601-933-6596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13895
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: