=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396428157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES C JOHNSON DO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2023
-----------------------------------------------------
Last Update Date | 09/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3141 BEAUMONT CENTRE CIR STE 103
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40513-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-523-0058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3141 BEAUMONT CENTRE CIR STE 103
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40513-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-523-0058
-----------------------------------------------------
Fax | 859-309-9998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN / OWNER
-----------------------------------------------------
Name | DR. CHARLES JOHNSON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 859-806-1598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------