Provider Demographics
NPI:1376757708
Name:JOHNSON, WILLIAM DOLPH (PA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DOLPH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3707
Mailing Address - Country:US
Mailing Address - Phone:631-833-4216
Mailing Address - Fax:718-578-4540
Practice Address - Street 1:5968 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2001
Practice Address - Country:US
Practice Address - Phone:631-929-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY35A413Medicare ID - Type UnspecifiedGROUP WBW 771