Provider Demographics
NPI:1477588218
Name:JOHNSON, BERTRAM LEE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:LEE
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 OREGON PIKE STE 2
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1821 OREGON PIKE STE 2
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6466
Practice Address - Country:US
Practice Address - Phone:717-569-7100
Practice Address - Fax:717-569-3011
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012613E174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000602572Medicaid
PA233072995OtherTID
PA063746GTEMedicare PIN
PAC28685Medicare UPIN