Healthcare Provider Details

I. General information

NPI: 1750375598
Provider Name (Legal Business Name): CYNDA ANN JOHNSON MD MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date: 06/14/2006
Reactivation Date: 02/06/2007

III. Provider practice location address

600 MOYE BLVD FAMILY PRACTICE CENTER
GREENVILLE NC
27834-4300
US

IV. Provider business mailing address

2200 SOUTH CHARLES BLVD GREENVILLE CENTRE ROOM 1515
GREENVILLE NC
27858-4353
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-4611
  • Fax: 252-744-4614
Mailing address:
  • Phone: 252-328-9478
  • Fax: 252-328-2769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200400689
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number200400689
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: