Provider Demographics
NPI:1497724926
Name:JOHNSON, CLEVELAND ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:CLEVELAND
Middle Name:ERIC
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 1:840 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2711
Mailing Address - Country:US
Mailing Address - Phone:601-426-6401
Mailing Address - Fax:601-425-7510
Practice Address - Street 1:424 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4345
Practice Address - Country:US
Practice Address - Phone:601-649-5990
Practice Address - Fax:601-425-7510
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05931207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012410Medicaid
MSB31146Medicare UPIN
MS20000065Medicare ID - Type Unspecified