Healthcare Provider Details

I. General information

NPI: 1255710810
Provider Name (Legal Business Name): MATTHEW JEFFREY JOHNSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 MEDICAL PARK RD STE 300
MOORESVILLE NC
28117-8544
US

IV. Provider business mailing address

125 TRADE CT # 26
MOORESVILLE NC
28117-5545
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-9995
  • Fax: 704-360-2221
Mailing address:
  • Phone: 704-360-9995
  • Fax: 704-360-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019-02699
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2019-02699
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: