Provider Demographics
NPI:1730475914
Name:JOHNSON, WENDELL SEBASTIAN (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:SEBASTIAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08882-1605
Mailing Address - Country:US
Mailing Address - Phone:908-208-1643
Mailing Address - Fax:
Practice Address - Street 1:47 CHARLES ST
Practice Address - Street 2:
Practice Address - City:SOUTH RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08882-1605
Practice Address - Country:US
Practice Address - Phone:908-208-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-25
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program