Healthcare Provider Details

I. General information

NPI: 1417242553
Provider Name (Legal Business Name): CANDACE L JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 BROADWAY SUITE 106
NEW YORK NY
10032-1559
US

IV. Provider business mailing address

622 W 168TH ST PH4-474
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6490
  • Fax: 212-342-5218
Mailing address:
  • Phone: 212-305-6490
  • Fax: 212-342-5218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number276035
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number276035
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: