Provider Demographics
NPI:1497887293
Name:JOHNSON, MITZI (MD)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
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 1:111 GROSSMAN DR
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4997
Mailing Address - Country:US
Mailing Address - Phone:781-849-2300
Mailing Address - Fax:781-849-2593
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-2300
Practice Address - Fax:781-849-2593
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59642208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice