Provider Demographics
NPI:1295821270
Name:JOHNSON, CHARLES E (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
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 1:3115 HEATHERIDGE LANE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509
Mailing Address - Country:US
Mailing Address - Phone:775-250-3675
Mailing Address - Fax:775-329-4921
Practice Address - Street 1:1664 N. VIRGINIA ST.
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89557
Practice Address - Country:US
Practice Address - Phone:775-784-1110
Practice Address - Fax:775-329-4921
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4556207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20-16337Medicaid
NV20-16337Medicaid
NVWQBBM01Medicare ID - Type Unspecified