Provider Demographics
NPI:1033292339
Name:JOHNSON, JEROME GORDON (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
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 1:1200 J D ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3494
Mailing Address - Country:US
Mailing Address - Phone:304-285-3679
Mailing Address - Fax:304-285-3694
Practice Address - Street 1:1000 MON HEALTH MEDICAL PARK DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1104
Practice Address - Country:US
Practice Address - Phone:304-599-1448
Practice Address - Fax:304-599-5335
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV08973208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0127517000Medicaid
WVWV5365C185OtherMEDICARE
001719639OtherBLUE CROSS BLUE SHIELD
WV0127517000Medicaid
001719639OtherBLUE CROSS BLUE SHIELD
0767620OtherMEDICAID OF OHIO
WV08973AOtherHEALTHPLAN UPPER OHIO VAL
WVA71828Medicare UPIN
7010061Medicare ID - Type Unspecified
WV0127517000Medicaid