Provider Demographics
NPI:1669415972
Name:JOHNSON, JERRY C (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:C
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 1:3615 CHESTNUT ST
Mailing Address - Street 2:RALSTON PENN CENTER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2612
Mailing Address - Country:US
Mailing Address - Phone:215-662-2746
Mailing Address - Fax:215-349-5648
Practice Address - Street 1:3615 CHESTNUT ST
Practice Address - Street 2:RALSTON PENN CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-2746
Practice Address - Fax:215-349-5648
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019829E207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007361000007Medicaid
PA058994Medicare PIN
C28595Medicare UPIN