Healthcare Provider Details

I. General information

NPI: 1639153596
Provider Name (Legal Business Name): SANDRA DIANE JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MILL ROAD
FAIRHAVEN MA
02719-5252
US

IV. Provider business mailing address

200 MILL RD SUITE 180
FAIRHAVEN MA
02719-5252
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-2432
  • Fax: 508-973-2435
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD11384
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number231054
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: