Healthcare Provider Details

I. General information

NPI: 1801209713
Provider Name (Legal Business Name): MATTHEW JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH STREET
LEBANON PA
17042
US

IV. Provider business mailing address

4524 WOODLAWN DR
EMMAUS PA
18049-1250
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-2700
  • Fax: 717-272-2757
Mailing address:
  • Phone: 423-552-6587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL36689
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS019404
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102207758
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: