Provider Demographics
NPI:1134176530
Name:JOHNSON, AMY MARIE (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
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:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - Street 2:PO BOX 40,000 DEPT 634
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06151-0634
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:HARTFORD HOSPITAL OBGYN DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102
Practice Address - Country:US
Practice Address - Phone:860-545-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044259207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI54387Medicare UPIN