Healthcare Provider Details

I. General information

NPI: 1245292853
Provider Name (Legal Business Name): AMY S. JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 10TH ST SUITE 101
POCOMOKE MD
21851-1607
US

IV. Provider business mailing address

305 10TH ST SUITE 101
POCOMOKE MD
21851-1607
US

V. Phone/Fax

Practice location:
  • Phone: 410-957-3005
  • Fax: 410-957-0550
Mailing address:
  • Phone: 410-957-3005
  • Fax: 410-957-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0058928
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: