Provider Demographics
NPI:1770546277
Name:JOHNSON, ERIC ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:ROBERT
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 1:59 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420
Mailing Address - Country:US
Mailing Address - Phone:585-637-6120
Mailing Address - Fax:585-637-4772
Practice Address - Street 1:59 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420
Practice Address - Country:US
Practice Address - Phone:585-637-6120
Practice Address - Fax:585-637-4772
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180005208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01414933Medicaid
NY01414933Medicaid
NY11087BMedicare ID - Type Unspecified