Provider Demographics
NPI:1285636076
Name:JOHNSON, CHARLES S (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1072 X RAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:315 19TH ST SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4230
Practice Address - Country:US
Practice Address - Phone:828-325-9849
Practice Address - Fax:828-325-9879
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200100712207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136XWMedicaid
NC89136XWMedicaid
NC2028905Medicare PIN