Provider Demographics
NPI:1902830433
Name:JOHNSON, PAUL R (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
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 1079
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21651
Mailing Address - Country:US
Mailing Address - Phone:410-778-0088
Mailing Address - Fax:410-778-9592
Practice Address - Street 1:400 S CROSS ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-4752
Practice Address - Country:US
Practice Address - Phone:410-778-0088
Practice Address - Fax:410-778-9592
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00524872086S0129X, 208D00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD642M143FMedicare PIN
MDE89409Medicare UPIN