Provider Demographics
NPI:1831118868
Name:JOHNSON, MARK ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTONIO
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 1:1160 VARNUM ST NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2107
Mailing Address - Country:US
Mailing Address - Phone:202-448-4014
Mailing Address - Fax:202-448-4082
Practice Address - Street 1:1140 VARNUM STREET NE
Practice Address - Street 2:SUITE 106
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:202-448-4014
Practice Address - Fax:202-448-4082
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD30469208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
2063270OtherAETNA
52821OtherAMERIGROUP
16077OtherCHARTERED HEALTH PLAN
MD529000700Medicaid
DC017148800Medicaid
392560OtherUNITED HEALTHCARE MAMSI
F7920001OtherBLUE CROSS
G84686Medicare UPIN
MD529000700Medicaid