1114943263 NPI number — DOUGLAS ROSS JOHNSON M.D.

Table of content: DOUGLAS ROSS JOHNSON M.D. (NPI 1114943263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114943263 NPI number — DOUGLAS ROSS JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
DOUGLAS
Provider Middle Name:
ROSS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114943263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636256 CENTRAL CREDENTIALING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-6256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-585-5507
Provider Business Mailing Address Fax Number:
513-585-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 GOODMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45219-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-584-3832
Provider Business Practice Location Address Fax Number:
513-584-3807
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0500X , with the licence number:  35 121319 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 35121319 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64064181 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB 5773 . This is a "RR GROUP#" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 37903705 . This is a "MEDICAID LAB GROUP#" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4000501 . This is a "MEDICARE LAB GROUP#" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 220033608 . This is a "RR MEDICARE PIN#" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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