Provider Demographics
NPI:1205931052
Name:JOHNSON, LISA MARGUERITE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARGUERITE
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 1:400 E 77TH ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-2303
Mailing Address - Country:US
Mailing Address - Phone:212-861-2564
Mailing Address - Fax:212-861-2569
Practice Address - Street 1:400 E 77TH ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-2303
Practice Address - Country:US
Practice Address - Phone:212-861-2564
Practice Address - Fax:212-861-2569
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206723207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01991588Medicaid
NYA300038567OtherMEDICARE PTAN
NY01991588Medicaid