Healthcare Provider Details

I. General information

NPI: 1184629776
Provider Name (Legal Business Name): CAROL G JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 E COUNTY LINE RD STE B2
INDIANAPOLIS IN
46227-2933
US

IV. Provider business mailing address

2086 FOX MOOR TER
GREENWOOD IN
46143-9276
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-6060
  • Fax: 317-859-5946
Mailing address:
  • Phone: 317-887-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01037716
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: