Provider Demographics
NPI:1477597094
Name:JOHNSON, REBECCA J (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IN
Mailing Address - Zip Code:46542-3004
Mailing Address - Country:US
Mailing Address - Phone:574-658-4142
Mailing Address - Fax:574-658-3160
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IN
Practice Address - Zip Code:46542-3004
Practice Address - Country:US
Practice Address - Phone:574-658-4142
Practice Address - Fax:574-658-3160
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002877A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200280270Medicaid
IN262490HMedicare PIN
134580EMedicare PIN
134700PMedicare PIN
I29848Medicare UPIN
453220CCMedicare PIN