Provider Demographics
NPI:1467418293
Name:JOHNSON, PHILIP EVAN PRESTON (M D)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:EVAN PRESTON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:RUTLEDGE
Mailing Address - State:PA
Mailing Address - Zip Code:19070-2102
Mailing Address - Country:US
Mailing Address - Phone:610-543-8888
Mailing Address - Fax:610-544-7612
Practice Address - Street 1:127 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:RUTLEDGE
Practice Address - State:PA
Practice Address - Zip Code:19070-2102
Practice Address - Country:US
Practice Address - Phone:610-543-8888
Practice Address - Fax:610-544-7612
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026166E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0975557Medicaid
PAC32363Medicare UPIN