Provider Demographics
NPI:1689674111
Name:JOHNSON, JERI BENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JERI
Middle Name:BENTON
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:5131 ODONOVAN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4791
Practice Address - Country:US
Practice Address - Phone:225-374-0220
Practice Address - Fax:225-374-0221
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14002R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1187771Medicaid
LA110232767OtherRAILROAD MEDICARE
LA110232767OtherRAILROAD MEDICARE
LA4A926D279Medicare PIN