Provider Demographics
NPI:1083600704
Name:JOHNSON, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
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 1:1611 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4302
Mailing Address - Country:US
Mailing Address - Phone:617-661-5100
Mailing Address - Fax:
Practice Address - Street 1:29 CRAFTS ST SUITE 400
Practice Address - Street 2:NEWTON
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1393
Practice Address - Country:US
Practice Address - Phone:617-964-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216904207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2801636Medicaid
MA2801636Medicaid
MAA36830Medicare PIN