Healthcare Provider Details

I. General information

NPI: 1053410662
Provider Name (Legal Business Name): L DAVID JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 PHYSICIANS DR
JACKSON TN
38305-2070
US

IV. Provider business mailing address

24 PHYSICIANS DR
JACKSON TN
38305-2070
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-9825
  • Fax: 731-668-6757
Mailing address:
  • Phone: 731-661-9825
  • Fax: 731-668-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number17211
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: