Provider Demographics
NPI:1972785715
Name:JOHNSON, ERIC D (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 WAL-MART PLAZA RD UNIT #4
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-2314
Mailing Address - Country:US
Mailing Address - Phone:606-340-0009
Mailing Address - Fax:606-340-0113
Practice Address - Street 1:75 WAL-MART PLAZA RD UNIT #4
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2314
Practice Address - Country:US
Practice Address - Phone:606-340-0009
Practice Address - Fax:606-340-0113
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY335562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64353568Medicaid
KYP00839671OtherRAILROAD MEDICARE
KY01172001Medicare PIN