=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003811985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY O JOHNSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2005
-----------------------------------------------------
Last Update Date | 09/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 BYPASS RD BLDG A
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41501-1689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-430-2205
-----------------------------------------------------
Fax | 606-218-7507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 432
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41502-0432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-430-2205
-----------------------------------------------------
Fax | 606-218-7507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2002-00267
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 230012
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 44838
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------