Provider Demographics
NPI:1124040738
Name:JOHNSON, PAUL E (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
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 1:201 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2805
Mailing Address - Country:US
Mailing Address - Phone:860-536-3078
Mailing Address - Fax:860-444-2015
Practice Address - Street 1:201 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2805
Practice Address - Country:US
Practice Address - Phone:860-536-3078
Practice Address - Fax:860-444-2015
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018242207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1182427Medicaid
CTD80685Medicare UPIN