Provider Demographics
NPI:1871550558
Name:JOHNSON, ERIC GORDON (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:GORDON
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 1:200 S HERLONG AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3399
Mailing Address - Country:US
Mailing Address - Phone:803-325-1770
Mailing Address - Fax:803-325-1790
Practice Address - Street 1:200 S HERLONG AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3399
Practice Address - Country:US
Practice Address - Phone:803-325-1770
Practice Address - Fax:803-325-1790
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890631KMedicaid
SC096915Medicaid
NC890631KMedicaid
SCP00714927Medicare PIN
SCD175719106Medicare PIN