Provider Demographics
NPI:1245371152
Name:JOHNSON, EDWARD ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ANTHONY
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 1:7910 ANDRUS RD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3171
Mailing Address - Country:US
Mailing Address - Phone:703-780-9465
Mailing Address - Fax:703-780-2568
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:301-618-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00407252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC004718A75Medicare PIN
MDF76923Medicare UPIN