Healthcare Provider Details

I. General information

NPI: 1508363672
Provider Name (Legal Business Name): GRETCHEN JOHNSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8102 CLEARVISTA PKWY
INDIANAPOLIS IN
46256-1661
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-849-8222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number02005876A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: