Healthcare Provider Details

I. General information

NPI: 1205931052
Provider Name (Legal Business Name): LISA MARGUERITE JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 77TH ST SUITE 1A
NEW YORK NY
10075-2303
US

IV. Provider business mailing address

400 E 77TH ST SUITE 1A
NEW YORK NY
10075-2303
US

V. Phone/Fax

Practice location:
  • Phone: 212-861-2564
  • Fax: 212-861-2569
Mailing address:
  • Phone: 212-861-2564
  • Fax: 212-861-2569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number206723
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: