Provider Demographics
NPI:1710037262
Name:LEGGETT-JOHNSON, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:LEGGETT-JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:A
Other - Last Name:LEGGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:KAISER PERMANENTE, MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:2101 E JEFFERSON ST
Practice Address - Street 2:3 EAST
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4908
Practice Address - Country:US
Practice Address - Phone:301-816-6544
Practice Address - Fax:301-816-6241
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38149207R00000X
DCMD18057207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
721785M92Medicare ID - Type Unspecified
B64715Medicare UPIN