Provider Demographics
NPI:1528401650
Name:DR. GOLDA JOHNSON, M.D. P.C.
Entity Type:Organization
Organization Name:DR. GOLDA JOHNSON, M.D. P.C.
Other - Org Name:GOLDA O JOHNSON MD, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GOLDA
Authorized Official - Middle Name:O
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-773-0975
Mailing Address - Street 1:910 PARK PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4013
Mailing Address - Country:US
Mailing Address - Phone:718-773-0975
Mailing Address - Fax:718-773-0529
Practice Address - Street 1:910 PARK PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4000
Practice Address - Country:US
Practice Address - Phone:718-773-0975
Practice Address - Fax:718-773-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174977207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01076984Medicaid
NYA61487Medicare UPIN
NY01076984Medicaid