Provider Demographics
NPI:1598054710
Name:JOHNSON, ERIC WALTER (PH D)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WALTER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LITCHFIELD ROAD
Mailing Address - Street 2:P.O. BOX 1
Mailing Address - City:NORFOLK
Mailing Address - State:CT
Mailing Address - Zip Code:06058
Mailing Address - Country:US
Mailing Address - Phone:860-689-5814
Mailing Address - Fax:
Practice Address - Street 1:203 LITCHFIELD ROAD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:CT
Practice Address - Zip Code:06058
Practice Address - Country:US
Practice Address - Phone:860-689-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT07D0995237291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJOHNE2OtherNEW YORK CQ
NYJOHNE2OtherNEW YORK STATE DOH CERTIFICATE OF QUALIFICATION