Provider Demographics
NPI:1265591952
Name:JOHNSON-HALL, SHIRLEY (MD)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:JOHNSON-HALL
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 1:931 HALLOCK AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-331-7200
Mailing Address - Fax:631-331-8636
Practice Address - Street 1:931 HALLOCK AVENUE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-331-7200
Practice Address - Fax:631-331-8636
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234410174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI29605Medicare UPIN
NYI29605Medicare UPIN