Healthcare Provider Details

I. General information

NPI: 1467751495
Provider Name (Legal Business Name): DR. TERRY D. JOHNSON, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N HIGHWAY 52
MONCKS CORNER SC
29461-3132
US

IV. Provider business mailing address

PO BOX 17190 MEDICAL STAFF OFFICE
LAS VEGAS NV
89114-7190
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-0936
  • Fax: 843-761-0938
Mailing address:
  • Phone: 702-560-2916
  • Fax: 702-560-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7353
License Number StateSC

VIII. Authorized Official

Name: DR. TERRY DUANE JOHNSON
Title or Position: PRESIDENT / CEO
Credential: M.D.
Phone: 864-590-6561