Provider Demographics
NPI:1659403905
Name:JOHNSON, SHAMALON R (MD)
Entity Type:Individual
Prefix:
First Name:SHAMALON
Middle Name:R
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 1:2209 BARONNE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70113-1501
Mailing Address - Country:US
Mailing Address - Phone:504-909-1027
Mailing Address - Fax:
Practice Address - Street 1:2115 CARONDELET ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-5827
Practice Address - Country:US
Practice Address - Phone:504-517-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2007732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1075302Medicaid
LA4N218D670Medicare PIN
LAP01316242Medicare PIN
LA338714YYSXMedicare PIN