Healthcare Provider Details

I. General information

NPI: 1982650289
Provider Name (Legal Business Name): BRUCE DEWAYNE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 W 5TH ST
COOKEVILLE TN
38501-1760
US

IV. Provider business mailing address

1092 SUGARHILL PL
COOKEVILLE TN
38501-4538
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-2541
  • Fax: 530-243-0445
Mailing address:
  • Phone: 931-261-7399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD0000040859
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: