Healthcare Provider Details

I. General information

NPI: 1457304131
Provider Name (Legal Business Name): SAMUEL T JOHNSON SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 HIGHWAY 51 S
BRIGHTON TN
38011-6921
US

IV. Provider business mailing address

PO BOX 507
COVINGTON TN
38019-0507
US

V. Phone/Fax

Practice location:
  • Phone: 901-475-4752
  • Fax: 901-475-1554
Mailing address:
  • Phone: 901-475-4752
  • Fax: 901-475-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD11374
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: