Provider Demographics
NPI:1285794107
Name:JOHNSON, GARY RUSSELL (PT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:RUSSELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 1ST SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39669-3777
Mailing Address - Country:US
Mailing Address - Phone:601-888-7944
Mailing Address - Fax:601-888-4676
Practice Address - Street 1:558 1ST SOUTH ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-3777
Practice Address - Country:US
Practice Address - Phone:601-888-7944
Practice Address - Fax:601-888-4676
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126497Medicaid
MS00126497Medicaid