Healthcare Provider Details

I. General information

NPI: 1780277194
Provider Name (Legal Business Name): AVERY WILLIAM JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-0196
  • Fax:
Mailing address:
  • Phone: 619-881-9169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101275950
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: