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General NPI Number Information
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NPI Number | 1407430721
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Entity Type | Individual
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Provider Name | ZACKERY JOHNSON DO
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Gender | Male
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Dates
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Enumeration Date | 05/12/2021
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Last Update Date | 09/30/2024
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Provider Practice Location Address
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Address Line | 1320 MAPLEWOOD AVE
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City | RONCEVERTE
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State | WV
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Zip | 24970-8016
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Country | US
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Telephone | 43-647-4411
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Fax |
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Provider Business Mailing Address
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Address Line | 400 ASSOCIATION DR STE 102
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City | CHARLESTON
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State | WV
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Zip | 25311-1298
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Country | US
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Telephone | 304-388-1724
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Fax | 304-388-1721
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | OT020569
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 4395
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License Number State | WV
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