Provider Demographics
NPI:1649731738
Name:JOHNSON, CASSANDRA MARIA
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 E 56TH ST # 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-3204
Mailing Address - Country:US
Mailing Address - Phone:646-844-8342
Mailing Address - Fax:352-594-1926
Practice Address - Street 1:60 E 56TH ST # 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-3204
Practice Address - Country:US
Practice Address - Phone:646-844-8342
Practice Address - Fax:352-594-1926
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS19872207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118418600Medicaid