Healthcare Provider Details

I. General information

NPI: 1588626501
Provider Name (Legal Business Name): PEGGY LYN JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WINTER ST SUITE 802
BOSTON MA
02108-4720
US

IV. Provider business mailing address

1245 ADAMS ST # B303
DORCHESTER MA
02124-5799
US

V. Phone/Fax

Practice location:
  • Phone: 617-426-0600
  • Fax:
Mailing address:
  • Phone: 617-905-1273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number59013
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: