Provider Demographics
NPI:1346253846
Name:JOHNSON, DENISE AUDREY (MD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:AUDREY
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 1:751 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2559
Mailing Address - Country:US
Mailing Address - Phone:814-333-5436
Mailing Address - Fax:814-333-5561
Practice Address - Street 1:751 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2559
Practice Address - Country:US
Practice Address - Phone:814-333-5436
Practice Address - Fax:814-333-5561
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059320L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
205074OtherUPMC
876176OtherBLUE SHIELD
PA0015873630002Medicaid
PA0015873630002Medicaid
G28882Medicare UPIN