Provider Demographics
NPI:1790764207
Name:JOHNSON, JOHN H
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16662
Mailing Address - Country:US
Mailing Address - Phone:814-793-4833
Mailing Address - Fax:814-793-4834
Practice Address - Street 1:300 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-5210
Practice Address - Country:US
Practice Address - Phone:814-943-1272
Practice Address - Fax:814-940-8516
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044867E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE83725Medicare UPIN