Provider Demographics
NPI:1821079112
Name:JOHNSON, SANDRA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:RENEE
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 1:6655 SYKESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7966
Mailing Address - Country:US
Mailing Address - Phone:410-970-7284
Mailing Address - Fax:
Practice Address - Street 1:6655 SYKESVILLE RD
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-7966
Practice Address - Country:US
Practice Address - Phone:410-970-7284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00582602084P0800X
SC130452084P0800X
GA306572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E88101Medicare UPIN