Basic Information
| Provider Information | |||||||||
| NPI: | 1750342879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CLANFORD | ||||||||
| MiddleName: | LYONEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 S SUBER RD | ||||||||
| Address2: | |||||||||
| City: | GREER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296500944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649894609 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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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 | 200400688 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25112 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5904663 | 05 | NC | MEDICAID | P00329935 | 01 | NC | RAILROAD MEDICARE | OTHER |