Healthcare Provider Details

I. General information

NPI: 1932463445
Provider Name (Legal Business Name): AMY W JOHNSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY WIRTZ

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST OPW M200
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-656-4260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02004606A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11016694A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number02004606A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: