1568497675 NPI number — DR. MELVIN RUSSELL JOHNSON M.D.

Table of content: DR. MELVIN RUSSELL JOHNSON M.D. (NPI 1568497675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568497675 NPI number — DR. MELVIN RUSSELL JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MELVIN
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
DR.
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:
1568497675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4001 COLISEUM DR
Provider Second Line Business Mailing Address:
STE 310
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23666-6257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-827-2025
Provider Business Mailing Address Fax Number:
757-275-9802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 COLISEUM DR
Provider Second Line Business Practice Location Address:
STE 310
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666-6257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-827-2025
Provider Business Practice Location Address Fax Number:
757-275-9802
Provider Enumeration Date:
07/11/2006

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: 207R00000X , with the licence number:  0101-030884 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6009654 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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