Provider Demographics
NPI:1922077619
Name:THOTTAM, JOHNSON J (MD)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:J
Last Name:THOTTAM
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 1:4800 HIGBEE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2528
Mailing Address - Country:US
Mailing Address - Phone:330-492-8521
Mailing Address - Fax:330-492-1967
Practice Address - Street 1:4800 HIGBEE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2528
Practice Address - Country:US
Practice Address - Phone:330-492-8521
Practice Address - Fax:330-492-1967
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH37564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0366303Medicaid
OH0447732Medicare ID - Type Unspecified
OH0366303Medicaid