Healthcare Provider Details

I. General information

NPI: 1932462462
Provider Name (Legal Business Name): DORETT J JOHNSON-AGU MSC. EDUCATION
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MEMPHIS AVE
SOUTH FLORAL PARK NY
11001-3548
US

IV. Provider business mailing address

151 MEMPHIS AVE
SOUTH FLORAL PARK NY
11001-3548
US

V. Phone/Fax

Practice location:
  • Phone: 516-380-7318
  • Fax:
Mailing address:
  • Phone: 516-380-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8440
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: