Provider Demographics
NPI:1043234925
Name:JOHNSON, ROBERT ALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALBERT
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:PO BOX 61094
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23466-1094
Mailing Address - Country:US
Mailing Address - Phone:757-499-4949
Mailing Address - Fax:757-499-0648
Practice Address - Street 1:293 INDEPENDENCE BLVD
Practice Address - Street 2:PEMBROKE FIVE, SUITE 330
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5466
Practice Address - Country:US
Practice Address - Phone:757-499-4949
Practice Address - Fax:757-499-0648
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F86223Medicare UPIN