Healthcare Provider Details

I. General information

NPI: 1750355384
Provider Name (Legal Business Name): RICHARD A JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 STANIFORD ST 2ND FL S50 200
BOSTON MA
02114
US

IV. Provider business mailing address

PO BOX 9142
CHARLSTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2914
  • Fax: 617-724-2135
Mailing address:
  • Phone: 617-726-2914
  • Fax: 617-726-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number33609
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33609
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: