Provider Demographics
NPI:1396769683
Name:JOHNSON, BETH A (MD)
Entity type:Individual
Prefix:MS
First Name:BETH
Middle Name:A
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 1:3333 BURNET AVENUE ML 7009
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4830
Mailing Address - Fax:513-636-7868
Practice Address - Street 1:3333 BURNET AVENUE ML 7009
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4830
Practice Address - Fax:513-636-7868
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI440762080P0202X
OH35.0939102080P0202X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2978765Medicaid
WI34176400Medicaid
WI002A 73-601Medicare ID - Type UnspecifiedMILWAUKEE COUNTY
OH2978765Medicaid
OH7402561Medicare PIN