Provider Demographics
NPI:1982263323
Name:JOHNSON, COLTON TYLER (MD)
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:TYLER
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-450-1397
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:86 WREN ST
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-1529
Practice Address - Country:US
Practice Address - Phone:803-450-1397
Practice Address - Fax:803-259-3250
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11020581A207Q00000X
SC88582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine