Provider Demographics
NPI:1285644146
Name:JOHNSON, TISHA K (MD, MPH)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2235
Mailing Address - Country:US
Mailing Address - Phone:859-233-4511
Mailing Address - Fax:859-281-3976
Practice Address - Street 1:1101 VETERANS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2235
Practice Address - Country:US
Practice Address - Phone:859-233-4511
Practice Address - Fax:859-281-3976
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061473207R00000X
OH35.087561207R00000X
KY444262083P0901X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3082800Medicaid
OH000000315186OtherOH MEDICAID UNISON
OHP00867121OtherRAILROAD MEDICARE
OH3082800OtherOH MEDICAID MOLINA
IN200853490Medicaid
WV3810018631Medicaid
OHP00867121OtherRAILROAD MEDICARE
INI51540Medicare UPIN
IN903630FMedicare PIN