Provider Demographics
NPI:1184629776
Name:JOHNSON, CAROL G (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1030 E COUNTY LINE RD
Practice Address - Street 2:STE B2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2933
Practice Address - Country:US
Practice Address - Phone:317-887-6060
Practice Address - Fax:317-859-5946
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087991OtherANTHEM
IN100102110Medicaid