Provider Demographics
NPI:1407430721
Name:JOHNSON, ZACKERY (DO)
Entity type:Individual
Prefix:
First Name:ZACKERY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ASSOCIATION DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1298
Mailing Address - Country:US
Mailing Address - Phone:304-388-1724
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:1320 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:043-647-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT020569207P00000X
WV4395207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine