Provider Demographics
NPI:1225086655
Name:JOHNSON, LENWORTH N (MD)
Entity Type:Individual
Prefix:
First Name:LENWORTH
Middle Name:N
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 1:1 HOPPIN ST
Mailing Address - Street 2:CORO WEST/STE 202
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4141
Mailing Address - Country:US
Mailing Address - Phone:401-444-6551
Mailing Address - Fax:
Practice Address - Street 1:1 HOPPIN ST
Practice Address - Street 2:CORO WEST/STE 202
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4141
Practice Address - Country:US
Practice Address - Phone:401-444-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7N60207W00000X
RIMD14426207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202887907Medicaid
MO804021OtherUNITED HEALTHCARE
MO9312OtherBLUE SHIELD/BLUE CHOICE
KS2086330901OtherKANSAS MEDICAID
MO131956OtherHEALTHLINK
MO002011910Medicare PIN
MO804021OtherUNITED HEALTHCARE
MO131956OtherHEALTHLINK
KS2086330901OtherKANSAS MEDICAID
MO202887907Medicaid