Provider Demographics
NPI:1568497675
Name:JOHNSON, MELVIN RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:RUSSELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4001 COLISEUM DR
Mailing Address - Street 2:STE 310
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6257
Mailing Address - Country:US
Mailing Address - Phone:757-827-2025
Mailing Address - Fax:757-275-9802
Practice Address - Street 1:4001 COLISEUM DR
Practice Address - Street 2:STE 310
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6257
Practice Address - Country:US
Practice Address - Phone:757-827-2025
Practice Address - Fax:757-275-9802
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-030884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6009654Medicaid
VA290000003Medicare PIN
C36654Medicare UPIN