Provider Demographics
NPI:1124632187
Name:JOHNSON, TATUM MAYFIELD
Entity type:Individual
Prefix:MRS
First Name:TATUM
Middle Name:MAYFIELD
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ORAL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-4021
Mailing Address - Country:US
Mailing Address - Phone:601-606-0558
Mailing Address - Fax:
Practice Address - Street 1:6766 U S HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8443
Practice Address - Country:US
Practice Address - Phone:601-549-4877
Practice Address - Fax:601-901-6061
Is Sole Proprietor?:No
Enumeration Date:2020-09-06
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS904349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program