Provider Demographics
NPI:1598732224
Name:JOHNSON, EDWIN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:MARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:640 S STATE ST
Mailing Address - Street 2:MAIL CODE 3055
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-480-1688
Mailing Address - Fax:302-480-9807
Practice Address - Street 1:802 N DUPONT BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1006
Practice Address - Country:US
Practice Address - Phone:302-422-6050
Practice Address - Fax:302-422-6685
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003314207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000025911Medicaid
DE1000025911Medicaid
E21839Medicare UPIN