Provider Demographics
NPI:1093914673
Name:JOHNSON, PETER MATHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MATHEW
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 1:1636 REGULUS AVE
Mailing Address - Street 2:COMNAVSPECWARDEVGRU
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23461-2200
Mailing Address - Country:US
Mailing Address - Phone:757-893-2026
Mailing Address - Fax:757-492-8409
Practice Address - Street 1:1636 REGULUS AVE
Practice Address - Street 2:COMNAVSPECWARDEVGRU
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23461-2200
Practice Address - Country:US
Practice Address - Phone:757-893-2026
Practice Address - Fax:757-492-8409
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA021875P95 - C03895Medicare PIN