Healthcare Provider Details

I. General information

NPI: 1134399025
Provider Name (Legal Business Name): CHARISSE D JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 FLORENCE AVE STE 233
GRANGER IN
46530-8048
US

IV. Provider business mailing address

229 FLORENCE AVE STE 233
GRANGER IN
46530-8048
US

V. Phone/Fax

Practice location:
  • Phone: 574-855-4575
  • Fax: 833-314-0410
Mailing address:
  • Phone: 574-855-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01068390A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200987950
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: