Provider Demographics
NPI:1144333030
Name:JOHNSON, VERNON LATRELL (MD)
Entity type:Individual
Prefix:DR
First Name:VERNON
Middle Name:LATRELL
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 1:5050 POPLAR AVE
Mailing Address - Street 2:718
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38157-0101
Mailing Address - Country:US
Mailing Address - Phone:901-443-0475
Mailing Address - Fax:901-509-2926
Practice Address - Street 1:5050 POPLAR AVE
Practice Address - Street 2:SUITE 718
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38157-0101
Practice Address - Country:US
Practice Address - Phone:901-443-0475
Practice Address - Fax:901-509-2926
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3CO7174400000X
MOR3C07207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201787314Medicaid
MO000002013Medicare ID - Type Unspecified
MO201787314Medicaid