Provider Demographics
NPI:1457674954
Name:DEGRAFT-JOHNSON MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:DEGRAFT-JOHNSON MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LATIFA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRAFT-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-669-5048
Mailing Address - Street 1:RR 1 BOX 6196
Mailing Address - Street 2:AGAPE MEDICAL CENTER
Mailing Address - City:KINGSHILL
Mailing Address - State:VI
Mailing Address - Zip Code:00850-9826
Mailing Address - Country:US
Mailing Address - Phone:340-772-2000
Mailing Address - Fax:340-778-9798
Practice Address - Street 1:RR 1 BOX 6196
Practice Address - Street 2:AGAPE MEDICAL CENTER
Practice Address - City:KINGSHILL
Practice Address - State:VI
Practice Address - Zip Code:00850-9826
Practice Address - Country:US
Practice Address - Phone:340-772-2000
Practice Address - Fax:340-778-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1578207Q00000X
VI1579208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538111471OtherNPI
VI1194970475OtherNPI
1538111471OtherNPI