Basic Information
| Provider Information | |||||||||
| NPI: | 1346470069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 DOROTHY FORD LN SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358017513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074514720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 GOVERNORS DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565514555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36023 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.