Provider Demographics
NPI:1528386729
Name:JOHNSON, JEREMY TODD (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2423
Mailing Address - Country:US
Mailing Address - Phone:269-217-2244
Mailing Address - Fax:
Practice Address - Street 1:27100 CHARDON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1116
Practice Address - Country:US
Practice Address - Phone:440-585-7006
Practice Address - Fax:440-585-6269
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.012569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program