Provider Demographics
NPI:1588692503
Name:JOHNSON, JODY MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:MICHAEL
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-5239
Mailing Address - Country:US
Mailing Address - Phone:606-889-6240
Mailing Address - Fax:606-886-9908
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:SUITE 3141
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653
Practice Address - Country:US
Practice Address - Phone:606-889-6240
Practice Address - Fax:606-886-9908
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02979207QA0401X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64121213Medicaid
KY00269Medicare PIN
137957Medicare UPIN