Healthcare Provider Details

I. General information

NPI: 1376382622
Provider Name (Legal Business Name): LAMART CROY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. LAMART DANNER JR.

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 EZZARD CHARLES DR
CINCINNATI OH
45214-2525
US

IV. Provider business mailing address

246 E CAMPUS VIEW BLVD
COLUMBUS OH
43235-4634
US

V. Phone/Fax

Practice location:
  • Phone: 513-381-6672
  • Fax:
Mailing address:
  • Phone: 502-735-7143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.005122
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: