Provider Demographics
NPI:1750412573
Name:JOHNSON, SHARON (MD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:
Last Name:JOHNSON
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 1:556 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1514
Mailing Address - Country:US
Mailing Address - Phone:973-482-8384
Mailing Address - Fax:973-482-8433
Practice Address - Street 1:741 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4309
Practice Address - Country:US
Practice Address - Phone:973-483-1300
Practice Address - Fax:973-483-3147
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA037786261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA037786OtherMEDICAL LICENSE #
NJBJ4625008OtherDEA #
NJD19889Medicare UPIN