Provider Demographics
NPI:1376908640
Name:JOHNSON, VONDA (MD)
Entity Type:Individual
Prefix:
First Name:VONDA
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:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:DANNEMORA
Mailing Address - State:NY
Mailing Address - Zip Code:12929-2000
Mailing Address - Country:US
Mailing Address - Phone:518-492-2511
Mailing Address - Fax:
Practice Address - Street 1:1156 COOK STREET
Practice Address - Street 2:CLINTON CORRECTIONAL FACILITY
Practice Address - City:DANNEMORA
Practice Address - State:NY
Practice Address - Zip Code:12929
Practice Address - Country:US
Practice Address - Phone:518-492-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine