Healthcare Provider Details

I. General information

NPI: 1285202952
Provider Name (Legal Business Name): MARY JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2097
US

IV. Provider business mailing address

451 CLARKSON AVE
BROOKLYN NY
11203-2097
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-3131
  • Fax:
Mailing address:
  • Phone: 718-245-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number340955
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: