Provider Demographics
NPI:1841259967
Name:JOHNSON, WESLEY D (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:D
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 1:100 FODEN RD W
Mailing Address - Street 2:STE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:259 MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096
Practice Address - Country:US
Practice Address - Phone:207-846-9013
Practice Address - Fax:207-523-8586
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
043392OtherANTHEM
2949928OtherAETNA
ME309940099Medicaid
MM940601Medicare PIN
MM9406Medicare ID - Type Unspecified
2949928OtherAETNA
ME309940099Medicaid
MESX1270Medicare PIN