Healthcare Provider Details

I. General information

NPI: 1265757769
Provider Name (Legal Business Name): MATTHEW ALAN JOHANSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 HARRISON AVE
CINCINNATI OH
45247-7961
US

IV. Provider business mailing address

6480 HARRISON AVE SUITE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 513-354-3700
  • Fax: 513-354-7651
Mailing address:
  • Phone: 513-354-3700
  • Fax: 513-354-7651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number0101258243
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberD79334
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number35.129257
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberTP268
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: