Provider Demographics
NPI:1538115209
Name:JOHNSON, JODIE L (MD)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:L
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7232 DEPT 165
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7232
Mailing Address - Country:US
Mailing Address - Phone:317-614-9817
Mailing Address - Fax:317-614-9655
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:866-282-7905
Practice Address - Fax:800-731-0751
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045348207LP3000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200215170Medicaid
INH16239Medicare UPIN
IN200215170Medicaid
IN095200QQQMedicare PIN