Provider Demographics
NPI:1194772178
Name:JOHNSON, GERALD (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:JOHNSON
Suffix:
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 1:6142 SHALLOWFORD RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7216
Mailing Address - Country:US
Mailing Address - Phone:423-498-3300
Mailing Address - Fax:423-498-3301
Practice Address - Street 1:6142 SHALLOWFORD RD STE 103
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7216
Practice Address - Country:US
Practice Address - Phone:423-498-3300
Practice Address - Fax:423-498-3301
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000322482080P0202X
PAMD4227222080P0202X
TN322482080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1008205830001Medicaid
PA73331Medicare ID - Type Unspecified
PA1008205830001Medicaid