Provider Demographics
NPI:1811065725
Name:JOHNSON, ISAIAH MICAH (MD)
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:MICAH
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5353
Mailing Address - Fax:
Practice Address - Street 1:102 HIGHLAND AVE SE
Practice Address - Street 2:SUITE 303
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2256
Practice Address - Country:US
Practice Address - Phone:540-985-9715
Practice Address - Fax:540-985-9890
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30001207V00000X
VA0101245336207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20064957OtherSELECT HEALTH
SCAA20658552Medicare PIN
SCAA20655819Medicare PIN