Provider Demographics
NPI:1669565396
Name:GONZALEZ MEJIA, JOHANNA JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:JACQUELINE
Last Name:GONZALEZ MEJIA
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 1:433 NORTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3398
Mailing Address - Country:US
Mailing Address - Phone:908-436-1002
Mailing Address - Fax:908-436-1109
Practice Address - Street 1:433 NORTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3398
Practice Address - Country:US
Practice Address - Phone:908-436-1002
Practice Address - Fax:908-436-1109
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06899700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ202092816OtherTAX ID,
NJAH0236165301OtherAMERIHEALTH
NJ60013229OtherHORIZON NJ HEALTH
NJ01000296602OtherAMERICHOICE
NJ97222OtherAMERIGROUP
NJ8565708Medicaid
NJ31002OtherUNIVERSITY HEALTH PLAN
NJ7752202OtherAETNA