Provider Demographics
NPI:1679581227
Name:JOHNSON, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8055 O ST
Mailing Address - Street 2:STE 300
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2580
Mailing Address - Country:US
Mailing Address - Phone:402-421-0896
Mailing Address - Fax:402-421-0945
Practice Address - Street 1:2200 S 40TH ST
Practice Address - Street 2:STE 104
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2407
Practice Address - Country:US
Practice Address - Phone:402-483-6000
Practice Address - Fax:402-483-6106
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE35833OtherBCBS
NE01-00145OtherUHC
NE1208OtherMIDLAND'S CHOICE
NE470780857 32Medicaid
E02394Medicare UPIN
275196Medicare ID - Type Unspecified
NE470780857 32Medicaid