Provider Demographics
NPI:1154365583
Name:JOHNSON, WILLIAM R JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:1819 W CLINCH AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2434
Practice Address - Country:US
Practice Address - Phone:865-524-1631
Practice Address - Fax:865-541-1727
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3033627Medicaid
TN080064816OtherRR MEDICARE PIN
TN3714823Medicare ID - Type UnspecifiedLEGACY GROUP
TN3033627Medicaid
A99724Medicare UPIN