Provider Demographics
NPI:1720154131
Name:JOHNSON, JOHN A (MD, MBA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 VAUX LINK
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-9683
Mailing Address - Country:US
Mailing Address - Phone:614-225-0400
Mailing Address - Fax:800-948-7705
Practice Address - Street 1:4319 VAUX LINK
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-9683
Practice Address - Country:US
Practice Address - Phone:614-225-0400
Practice Address - Fax:800-948-7705
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350690482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0173459Medicaid
OHG12427Medicare UPIN
OH0796792Medicare ID - Type Unspecified