Provider Demographics
NPI: | 1003859687 |
---|---|
Name: | JOHNSON, STEPHEN M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | STEPHEN |
Middle Name: | M |
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: | 1613 OAKWOOD ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BEDFORD |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 24523-1213 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 540-587-7810 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1613 OAKWOOD ST |
Practice Address - Street 2: | |
Practice Address - City: | BEDFORD |
Practice Address - State: | VA |
Practice Address - Zip Code: | 24523-1213 |
Practice Address - Country: | US |
Practice Address - Phone: | 540-587-7810 |
Practice Address - Fax: | 434-200-1657 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-13 |
Last Update Date: | 2014-10-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101037503 | 207RP1001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 239950 | Other | ANTHEM |
VA | 010286638 | Medicaid | |
VA | 1003859687 | Medicaid | |
VA | D27038 | Medicare UPIN | |
VA | P00411747 | Medicare PIN | |
VA | 011786C80 | Medicare PIN | |
VA | 010286638 | Medicaid | |
VA | 1003859687 | Medicaid |