Provider Demographics
NPI:1295800142
Name:JOHANNESSEN, DONALD J (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:JOHANNESSEN
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 1:425 E 79TH ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-1037
Mailing Address - Country:US
Mailing Address - Phone:212-249-4739
Mailing Address - Fax:212-737-5574
Practice Address - Street 1:425 E 79TH ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1037
Practice Address - Country:US
Practice Address - Phone:212-249-4739
Practice Address - Fax:212-737-5574
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1735032084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1557886Medicaid
NY33E581Medicare ID - Type Unspecified
NY1557886Medicaid