Provider Demographics
NPI:1538166673
Name:JOHANSEN, JAMES R (MD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:R
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28017-0778
Mailing Address - Country:US
Mailing Address - Phone:704-434-8123
Mailing Address - Fax:704-434-7262
Practice Address - Street 1:708 MCBRAYER HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-9532
Practice Address - Country:US
Practice Address - Phone:704-484-8123
Practice Address - Fax:704-434-7262
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9600957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8946700Medicaid
NC46700OtherNCBCBS
NC46700OtherNCBCBS
NC8946700Medicaid