Provider Demographics
NPI:1083706337
Name:JOHNSON-WEAVER, JOI ADRIA (MD)
Entity Type:Individual
Prefix:
First Name:JOI
Middle Name:ADRIA
Last Name:JOHNSON-WEAVER
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:PO BOX 418953
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8615 RIDGELYS CHOICE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-3026
Practice Address - Country:US
Practice Address - Phone:410-256-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10007760207Q00000X
MDD0068458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000038995Medicaid
MD790020100Medicaid
MD790020100Medicaid
MD712L/236857YBPGMedicare PIN
DE081803Medicare Oscar/Certification