Provider Demographics
NPI:1295899672
Name:JOHNSON, JEFFREY D (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 LINCOLN AVE, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-2104
Mailing Address - Country:US
Mailing Address - Phone:207-200-8814
Mailing Address - Fax:207-558-8980
Practice Address - Street 1:237 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:ME
Practice Address - Zip Code:04257-2603
Practice Address - Country:US
Practice Address - Phone:207-200-8814
Practice Address - Fax:207-558-8980
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1034213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME134880000Medicaid
MEME1822Medicare ID - Type Unspecified
ME134880000Medicaid