Provider Demographics
NPI:1609997121
Name:JOHNSON, NATHAN SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:SAMUEL
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 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:913-231-5161
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-5350
Practice Address - Country:US
Practice Address - Phone:913-231-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-355842085R0202X
MO20120091532085R0202X
FLME1733772085R0202X
OH35C.0025262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200877220AMedicaid
KSP01094625OtherRR MEDICARE
MOP01119931OtherRR MEDICARE
KS200877220BMedicaid
KSP01115725OtherRR MEDICARE
MOJ9600017Medicare PIN
KS200877220BMedicaid
KSJ96A00013Medicare PIN
MOP01119931OtherRR MEDICARE
MOJ96B00039Medicare PIN