Provider Demographics
NPI:1801896022
Name:JOHNSON, MARY H (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:H
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 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-4050
Mailing Address - Fax:276-258-4056
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-4050
Practice Address - Fax:276-258-4056
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27331207PP0204X
NC9401227207PP0204X
VA0101052591208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1801896022Medicaid
NC46440OtherBCBS
TNQ015237Medicaid
NC8946440Medicaid
NCNPIOtherMEDCOST
TN3891085Medicare PIN
TNQ015237Medicaid
VAVVJ061AMedicare PIN