Provider Demographics
NPI:1649413287
Name:JOHNSON, ROBERTA MAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:MAY
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 1:249 RT 11A
Mailing Address - Street 2:ONONDAGA NATION HEALTH CLINIC
Mailing Address - City:NEDROW
Mailing Address - State:NY
Mailing Address - Zip Code:13120-4500
Mailing Address - Country:US
Mailing Address - Phone:315-469-6994
Mailing Address - Fax:315-469-0593
Practice Address - Street 1:249 RT. 11 A
Practice Address - Street 2:
Practice Address - City:NEDROW
Practice Address - State:NY
Practice Address - Zip Code:13120-4500
Practice Address - Country:US
Practice Address - Phone:315-469-6994
Practice Address - Fax:315-469-0593
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine