Provider Demographics
NPI:1497711154
Name:JOHNSON, RAYMOND M (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:JOHNSON
Suffix:
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:PO BOX 44994
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46244-0994
Mailing Address - Country:US
Mailing Address - Phone:317-274-4402
Mailing Address - Fax:317-274-5168
Practice Address - Street 1:635 BARNHILL DR
Practice Address - Street 2:MS 224
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5126
Practice Address - Country:US
Practice Address - Phone:317-274-1427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054865207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200368540Medicaid
IN264910AFFFMedicare PIN
IN200368540Medicaid