Provider Demographics
NPI:1780881011
Name:JOHNSON, JONATHAN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
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 1:10275 LITTLE PATUXENT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3445
Mailing Address - Country:US
Mailing Address - Phone:888-464-2466
Mailing Address - Fax:
Practice Address - Street 1:137 E WILSON ST UNIT 711
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-4080
Practice Address - Country:US
Practice Address - Phone:347-756-1552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000468832084N0400X
WI52524-0202084N0400X
CAA1102622084N0400X
PAMD4360762084N0400X
NJ25MA086332002084N0400X
NY2486842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300028558Medicare PIN