Provider Demographics
NPI:1043206964
Name:JOHNSON, SARA J (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:315 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2817
Mailing Address - Country:US
Mailing Address - Phone:631-656-7161
Mailing Address - Fax:631-360-1546
Practice Address - Street 1:315 E MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2829
Practice Address - Country:US
Practice Address - Phone:631-360-7778
Practice Address - Fax:631-360-1546
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133527207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01049623Medicaid
NY11A562Medicare PIN
NY01049623Medicaid