Healthcare Provider Details

I. General information

NPI: 1780667501
Provider Name (Legal Business Name): STEPHEN E. JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6602 KNIGHTDALE BLVD SUITE 102
KNIGHTDALE NC
27545-6525
US

IV. Provider business mailing address

6602 KNIGHTDALE BLVD SUITE 102
KNIGHTDALE NC
27545-6525
US

V. Phone/Fax

Practice location:
  • Phone: 919-747-5210
  • Fax: 919-747-5211
Mailing address:
  • Phone: 919-747-5210
  • Fax: 919-747-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number42431
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21409
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: