Provider Demographics
NPI:1952320350
Name:JOHNSON, ELLEN D (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:D
Other - Last Name:GERETY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:22100 BOTHELL EVERETT HWY
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8431
Mailing Address - Country:US
Mailing Address - Phone:208-416-2932
Mailing Address - Fax:
Practice Address - Street 1:23 INGALLS VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:BOXFORD
Practice Address - State:MA
Practice Address - Zip Code:01921-2248
Practice Address - Country:US
Practice Address - Phone:208-416-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH110902085R0202X
VA01012760112085R0202X
MA2470422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7768225OtherAETNA
P00183990OtherRAILROAD MEDICARE
1204510OtherCIGNA
MA2081211Medicaid
ME286860099Medicaid
NH01Y003105NH02OtherANTHEM
NH30201338Medicaid
1204510OtherCIGNA
NH01Y003105NH02OtherANTHEM