Provider Demographics
NPI:1073763306
Name:JOHNSON, LISA MONIQUE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MONIQUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PARKWAY
Mailing Address - Street 2:PAYOR ENROLLMENT
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-585-5507
Mailing Address - Fax:
Practice Address - Street 1:3120 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3091
Practice Address - Country:US
Practice Address - Phone:513-584-8600
Practice Address - Fax:513-585-9018
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 101603207QA0000X
OH35.091443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine