Healthcare Provider Details

I. General information

NPI: 1659462190
Provider Name (Legal Business Name): MARK S. JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW # T3200
WASHINGTON DC
20060
US

IV. Provider business mailing address

2041 GEORGIA NW AVE TOWER 6101
WASHINGTON DC
20060-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-4440
  • Fax: 202-865-3214
Mailing address:
  • Phone: 202-865-6679
  • Fax: 202-865-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA05722100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: