Provider Demographics
NPI:1427296276
Name:JOHNSON, SAMUEL TERRY JR (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:TERRY
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 720
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-0720
Mailing Address - Country:US
Mailing Address - Phone:731-659-3125
Mailing Address - Fax:731-659-3131
Practice Address - Street 1:629 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1599
Practice Address - Country:US
Practice Address - Phone:731-658-3388
Practice Address - Fax:731-658-4079
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2011-12-14
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Provider Licenses
StateLicense IDTaxonomies
TN47830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I087769Medicare PIN