Provider Demographics
NPI:1679628432
Name:GARCIA, JOHANNY MAGNOLIA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNY
Middle Name:MAGNOLIA
Last Name:GARCIA
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 1:630 W 168TH ST # 4
Mailing Address - Street 2:VC 12TH FLOOR, SUITE 208
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220467207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02168610Medicaid
NY02168610Medicaid
NY34V281Medicare ID - Type Unspecified