Provider Demographics
NPI:1710057351
Name:JOHNSON, WILLIAM ROY KARL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROY KARL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:612 HARTFORD PIKE
Mailing Address - Street 2:MEDICAL CENTER OF NORTHEAST CONNECTICUT
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241
Mailing Address - Country:US
Mailing Address - Phone:860-779-0867
Mailing Address - Fax:860-779-0386
Practice Address - Street 1:612 HARTFORD PIKE
Practice Address - Street 2:MEDICAL CENTER OF NORTHEAST CONNECTICUT
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241
Practice Address - Country:US
Practice Address - Phone:860-779-0867
Practice Address - Fax:860-779-0386
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001228592Medicaid
CT001228592Medicaid
CT110001047Medicare ID - Type Unspecified