Provider Demographics
NPI:1275574766
Name:JOHNSON, MILLISAUN (MD)
Entity Type:Individual
Prefix:
First Name:MILLISAUN
Middle Name:
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 1:408 BERGEN AVE
Mailing Address - Street 2:JERSEY CITY
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-2202
Mailing Address - Country:US
Mailing Address - Phone:201-451-5137
Mailing Address - Fax:
Practice Address - Street 1:408 BERGEN AVE
Practice Address - Street 2:JERSEY CITY
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304
Practice Address - Country:US
Practice Address - Phone:201-451-5137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426038207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1872726OtherHIGHMARK BLUE SHIELD
PA30034506OtherKEYSTONE MERCY
PA1016568100002Medicaid
PA2732298000OtherKEYSTONE IBC
PA34936OtherHEALTH PARTNERS
PA101656810-01OtherAMERICHOICE-TC
PA1016568100001Medicaid
PA34937OtherHEALTH PARTNERS - BUCKS
PA2732298000OtherKEYSTONE IBC