Provider Demographics
NPI:1003810862
Name:JOHNSON PRIVITERA, CAMRON L (DO)
Entity Type:Individual
Prefix:
First Name:CAMRON
Middle Name:L
Last Name:JOHNSON PRIVITERA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:21 HIGHLAND AVE SE
Mailing Address - Street 2:STE 100
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-2218
Mailing Address - Country:US
Mailing Address - Phone:540-344-9213
Mailing Address - Fax:540-345-7559
Practice Address - Street 1:21 HIGHLAND AVE SE
Practice Address - Street 2:STE 100
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2218
Practice Address - Country:US
Practice Address - Phone:540-344-9213
Practice Address - Fax:540-345-7559
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102201592208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6830577OtherCIGNA
VA244013OtherSOUTHERN HEALTH
VA54088505618OtherJOHN DEERE
VA010072701Medicaid
VA139824OtherANTHEM
VA7861556OtherAETNA