Healthcare Provider Details

I. General information

NPI: 1700884046
Provider Name (Legal Business Name): ADEYEMI S JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 E 4TH ST STE 501
CHARLOTTE NC
28204-3260
US

IV. Provider business mailing address

1718 E 4TH ST STE 501
CHARLOTTE NC
28204-3260
US

V. Phone/Fax

Practice location:
  • Phone: 704-343-9800
  • Fax: 704-887-7570
Mailing address:
  • Phone: 704-343-9800
  • Fax: 704-887-7570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35671
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: