Provider Demographics
NPI:1457399297
Name:JOHNSON, WAYNE T (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:T
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 1:5838 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2663
Mailing Address - Country:US
Mailing Address - Phone:757-673-5680
Mailing Address - Fax:757-397-0236
Practice Address - Street 1:5838 HARBOUR VIEW BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2663
Practice Address - Country:US
Practice Address - Phone:757-673-5680
Practice Address - Fax:757-397-0236
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040647207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA200028241OtherMEDICARE RR
VA006405223Medicaid
VAP00799588OtherRR MEDICARE
VAP00799588OtherRR MEDICARE
VA006405223Medicaid
VA00Y208M07Medicare PIN