Provider Demographics
NPI:1033524202
Name:DR. GOLDA O JOHNSON MD, PC
Entity Type:Organization
Organization Name:DR. GOLDA O JOHNSON MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GOLDA
Authorized Official - Middle Name:ODETTE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-773-0975
Mailing Address - Street 1:910 PARK PL
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4000
Mailing Address - Country:US
Mailing Address - Phone:718-773-0975
Mailing Address - Fax:718-773-8844
Practice Address - Street 1:910 PARK PL
Practice Address - Street 2:SUITE 1B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4000
Practice Address - Country:US
Practice Address - Phone:718-773-0975
Practice Address - Fax:718-773-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174977207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03773911Medicaid