Provider Demographics
NPI:1578925715
Name:JOHNSON, NATHANIEL (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W COLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9404
Mailing Address - Country:US
Mailing Address - Phone:207-283-1602
Mailing Address - Fax:
Practice Address - Street 1:24 W COLE RD STE 104
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9404
Practice Address - Country:US
Practice Address - Phone:207-283-1602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-27
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT390200000X
MEMD24828208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program