Provider Demographics
NPI:1245806736
Name:JOHNSON, ALEX WALKER (DO)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:WALKER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FURROW LN
Mailing Address - Street 2:
Mailing Address - City:LADYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1272
Mailing Address - Country:US
Mailing Address - Phone:606-316-2562
Mailing Address - Fax:
Practice Address - Street 1:1664 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1708
Practice Address - Country:US
Practice Address - Phone:843-522-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12871207R00000X, 207W00000X
SC93824207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC93824OtherSC MEDICAL LICENSE
GA12871OtherGEORGIA RESIDENCY TRAINING PERMIT
SC938240Medicaid