Provider Demographics
NPI:1053599530
Name:JOHNSON, JIM M JR
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:M
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
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 109
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-0109
Mailing Address - Country:US
Mailing Address - Phone:803-534-1234
Mailing Address - Fax:
Practice Address - Street 1:1464 CAROLINA AVENUE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-1464
Practice Address - Country:US
Practice Address - Phone:803-534-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies