Healthcare Provider Details

I. General information

NPI: 1952320350
Provider Name (Legal Business Name): ELLEN D JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN D GERETY MD

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 INGALLS VILLAGE WAY
BOXFORD MA
01921-2248
US

IV. Provider business mailing address

22100 BOTHELL EVERETT HWY
BOTHELL WA
98021-8431
US

V. Phone/Fax

Practice location:
  • Phone: 208-416-2932
  • Fax:
Mailing address:
  • Phone: 208-416-2932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number11090
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101276011
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number247042
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: