Provider Demographics
NPI:1588626501
Name:JOHNSON, PEGGY LYN (MD)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:LYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 ADAMS ST # B303
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5799
Mailing Address - Country:US
Mailing Address - Phone:617-905-1273
Mailing Address - Fax:
Practice Address - Street 1:30 WINTER ST
Practice Address - Street 2:SUITE 802
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4720
Practice Address - Country:US
Practice Address - Phone:617-426-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA590132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1221905Medicaid
874948Medicare UPIN
MA1221905Medicaid