Provider Demographics
NPI:1821225046
Name:JOHNSON, OLGA KHODAKOVA (MD)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:KHODAKOVA
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 1:1606 MORGANTON RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4738
Mailing Address - Country:US
Mailing Address - Phone:910-484-3121
Mailing Address - Fax:910-221-2036
Practice Address - Street 1:1606 MORGANTON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-4738
Practice Address - Country:US
Practice Address - Phone:910-484-3121
Practice Address - Fax:910-221-2036
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8278611-1205208000000X
NC2013-00053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics