Provider Demographics
NPI:1477579100
Name:JOHNSON, JO BERNICE (MD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:BERNICE
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 1:333 LINCOLN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-3113
Mailing Address - Country:US
Mailing Address - Phone:207-283-3676
Mailing Address - Fax:207-283-3677
Practice Address - Street 1:333 LINCOLN ST STE 200
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-3113
Practice Address - Country:US
Practice Address - Phone:207-283-3676
Practice Address - Fax:207-283-3677
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME009193207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001617OtherBCBS
ME223570000Medicaid
MED03790Medicare UPIN
ME070040Medicare ID - Type Unspecified