Provider Demographics
NPI:1114955481
Name:JOHNSON, SUSAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
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 1:21 SCHOOL ST
Mailing Address - Street 2:STE 1
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6640
Mailing Address - Country:US
Mailing Address - Phone:413-727-3534
Mailing Address - Fax:413-341-1789
Practice Address - Street 1:82 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-788-0100
Practice Address - Fax:413-341-1789
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1320076Medicaid
MA1320076Medicaid