Healthcare Provider Details

I. General information

NPI: 1124257886
Provider Name (Legal Business Name): QUENTIN WANDYKE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6514 STATE ROUTE 26
ROME NY
13440-8079
US

IV. Provider business mailing address

6514 STATE ROUTE 26
ROME NY
13440-8079
US

V. Phone/Fax

Practice location:
  • Phone: 315-339-5232
  • Fax: 315-339-3698
Mailing address:
  • Phone: 315-339-5232
  • Fax: 315-339-3698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD296906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: