Provider Demographics
NPI:1306839550
Name:JOHNSON, DIANE LEE (MD, AAFP)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD, AAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 BIGGIN POND RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4589
Mailing Address - Country:US
Mailing Address - Phone:804-323-1264
Mailing Address - Fax:804-323-1276
Practice Address - Street 1:2367 COLONY CROSSING PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4280
Practice Address - Country:US
Practice Address - Phone:804-323-1264
Practice Address - Fax:804-323-1276
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VVF389AOtherMEDICARE PTAN
G86862Medicare UPIN
VA2261350OtherAETNA US HEALTHCARE
VA080006920Medicare PIN
VA0101673OtherUNITED HEALTHCARE
VA11044OtherCIGNA
VA20553OtherSENTARA
VA96471OtherSOUTHERN HEALTH/COVENTRY
VA871118OtherMDIPA
VA443482599OtherTRICARE/CHAMPUS
VA5638712Medicaid
VA12483Medicaid