Healthcare Provider Details

I. General information

NPI: 1497389142
Provider Name (Legal Business Name): BLAKE ELLIOT JOHNSON MD, M.SC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15830 BALLANTYNE MEDICAL PL STE 175
CHARLOTTE NC
28277-0763
US

IV. Provider business mailing address

15830 BALLANTYNE MEDICAL PL STE 175
CHARLOTTE NC
28277-0763
US

V. Phone/Fax

Practice location:
  • Phone: 704-248-3400
  • Fax: 704-337-8387
Mailing address:
  • Phone: 704-323-7633
  • Fax: 704-709-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2024-02754
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number97637
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: