Provider Demographics
NPI:1003850710
Name:JOHNSON, TODD L (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:L
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 1:4466 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2864
Mailing Address - Country:US
Mailing Address - Phone:330-489-1386
Mailing Address - Fax:330-489-1258
Practice Address - Street 1:4466 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2864
Practice Address - Country:US
Practice Address - Phone:330-489-1386
Practice Address - Fax:330-489-1258
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-2104-J207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003850710OtherMEDICARE RAILROAD
OH0253256Medicaid
OH0253256Medicaid
1003850710OtherMEDICARE RAILROAD