Provider Demographics
NPI:1427084367
Name:JOHNSON, GRETCHEN HEIDT (MD)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:HEIDT
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6308
Mailing Address - Fax:
Practice Address - Street 1:717 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3237
Practice Address - Country:US
Practice Address - Phone:864-522-5400
Practice Address - Fax:864-522-5405
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC164119Medicaid
SCSC7950F327Medicare PIN
SC8157Medicare PIN
SC164119Medicaid
SC164119Medicaid