Provider Demographics
NPI:1417242553
Name:JOHNSON, CANDACE L (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:PH4-474
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-6490
Mailing Address - Fax:212-342-5218
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:SUITE 106
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-305-6490
Practice Address - Fax:212-342-5218
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2017-03-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY276035208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics