1598284325 NPI number — MRS. MARY CATES JOHNSON RD

Table of content: MRS. MARY CATES JOHNSON RD (NPI 1598284325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598284325 NPI number — MRS. MARY CATES JOHNSON RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARY
Provider Middle Name:
CATES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598284325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 RURAL PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELMAR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12054-1104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-428-1405
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 MYRTLE AVE STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12208-3797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-262-4942
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2017

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: 133V00000X , with the licence number:  86049965 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 141338310 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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