Provider Demographics
NPI:1821039108
Name:JOHNSON, CARL (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
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:PO BOX 64664
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4664
Mailing Address - Country:US
Mailing Address - Phone:410-550-0453
Mailing Address - Fax:
Practice Address - Street 1:10753 FALLS RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-4535
Practice Address - Country:US
Practice Address - Phone:410-583-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26445207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD330191500Medicaid
MD330191500Medicaid
MDD76753Medicare UPIN