Provider Demographics
NPI:1780668236
Name:JOHNSON, GOLDA ODETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:GOLDA
Middle Name:ODETTE
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 1:910 PARK PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4000
Mailing Address - Country:US
Mailing Address - Phone:718-773-0975
Mailing Address - Fax:718-773-8844
Practice Address - Street 1:910 PARK PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4000
Practice Address - Country:US
Practice Address - Phone:718-773-0975
Practice Address - Fax:718-773-8844
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174977207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010022401OtherMEDICARE RAILROAD
NY01076984Medicaid
NY010022401OtherMEDICARE RAILROAD
NYA400094386Medicare PIN
NY24E271Medicare PIN