Provider Demographics
NPI:1073595799
Name:JOHNSON, MATTHEW A (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
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 1:1204 FENWICK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2323 MEMORIAL AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2661
Practice Address - Country:US
Practice Address - Phone:434-200-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005614023Medicaid
119865OtherANTHEM
080154922OtherMEDICARE RAILROAD PROVIDER NUMBER
VA005614023Medicaid
VV2314AMedicare PIN
080154922OtherMEDICARE RAILROAD PROVIDER NUMBER