Provider Demographics
NPI:1487640595
Name:JOHNSON, SUSANNA E (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:E
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 1:118 MOREY DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1646
Mailing Address - Country:US
Mailing Address - Phone:937-578-2796
Mailing Address - Fax:937-642-4136
Practice Address - Street 1:118 MOREY DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1646
Practice Address - Country:US
Practice Address - Phone:937-578-2796
Practice Address - Fax:937-642-4136
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-8759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2247312Medicaid
OH2247312Medicaid
OH4046948Medicare PIN