Provider Demographics
NPI:1386624419
Name:JOHNSON, CAROLE LEA (MD)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:LEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 W MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1345
Mailing Address - Country:US
Mailing Address - Phone:334-677-1690
Mailing Address - Fax:334-991-4656
Practice Address - Street 1:1733 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1345
Practice Address - Country:US
Practice Address - Phone:334-677-1690
Practice Address - Fax:334-699-1465
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18456207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL512-42252OtherBCBS
AL98483OtherBCBS