Provider Demographics
NPI:1528067840
Name:JOHNSON, EUNICE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:EUNICE
Middle Name:LOUISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 JETT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-9622
Mailing Address - Country:US
Mailing Address - Phone:606-666-6240
Mailing Address - Fax:606-666-6118
Practice Address - Street 1:540 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9622
Practice Address - Country:US
Practice Address - Phone:606-666-6240
Practice Address - Fax:606-666-6118
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21653207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64216237Medicaid
KY64216237Medicaid