Provider Demographics
NPI:1851311898
Name:JOHNSON, INGRID DENISE (MD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:DENISE
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 1:8640 SUDLEY RD STE 306
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4404
Mailing Address - Country:US
Mailing Address - Phone:703-330-3939
Mailing Address - Fax:
Practice Address - Street 1:8640 SUDLEY RD
Practice Address - Street 2:SUITE 306
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4420
Practice Address - Country:US
Practice Address - Phone:703-330-3939
Practice Address - Fax:703-331-0959
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6704433Medicaid