Provider Demographics
NPI:1861601916
Name:JOHNSON, COREY MORGAN (MD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:MORGAN
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1301 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 302
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-688-4480
Practice Address - Fax:270-688-4489
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069814A208800000X
KY44616208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100179530Medicaid
IN201029080Medicaid
INM400049778Medicare PIN
KYK013561Medicare PIN
IN249390016Medicare PIN
KYK013560Medicare PIN