Provider Demographics
NPI:1336306992
Name:JOHNSON, BEVERLY (MD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
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 1:1400 PELHAM PKWY S RM 3N-21E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1119
Mailing Address - Country:US
Mailing Address - Phone:718-918-3015
Mailing Address - Fax:718-918-7460
Practice Address - Street 1:1400 PELHAM PARKWAY SOUTH JACOBI MEDICAL CENTER
Practice Address - Street 2:ROOM 3N-06
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1197
Practice Address - Country:US
Practice Address - Phone:718-918-3015
Practice Address - Fax:718-918-7460
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247479207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine