Basic Information
Provider Information | |||||||||
NPI: | 1457360398 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | PAULA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DIX DENNERLEIN | ||||||||
OtherFirstName: | PAULA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 936 | ||||||||
Address2: |   | ||||||||
City: | LONDON | ||||||||
State: | KY | ||||||||
PostalCode: | 407430936 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063307818 | ||||||||
FaxNumber: | 6063307825 | ||||||||
Practice Location | |||||||||
Address1: | 4371 NEW SHEPHERDSVILLE RD UNIT 210 | ||||||||
Address2: |   | ||||||||
City: | BARDSTOWN | ||||||||
State: | KY | ||||||||
PostalCode: | 40004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023505373 | ||||||||
FaxNumber: | 5023505374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2006 | ||||||||
LastUpdateDate: | 08/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TP692 | KY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | TP692 | 01 | KY | STATE LIC | OTHER | 20455 | 01 | NE | STATE | OTHER |