Provider Demographics
NPI:1659462190
Name:JOHNSON, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 GEORGIA NW AVE TOWER 6101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20060-0001
Mailing Address - Country:US
Mailing Address - Phone:202-865-6679
Mailing Address - Fax:202-865-1617
Practice Address - Street 1:2041 GEORGIA AVE NW # T3200
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060
Practice Address - Country:US
Practice Address - Phone:202-865-4440
Practice Address - Fax:202-865-3214
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05722100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5128803Medicaid
NJ716356Medicare PIN
NJ5128803Medicaid