Healthcare Provider Details

I. General information

NPI: 1548257405
Provider Name (Legal Business Name): JAY A JOHANNIGMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-4504
US

IV. Provider business mailing address

340 NORMANDY AVE
SAN ANTONIO TX
78209-4541
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-3627
  • Fax:
Mailing address:
  • Phone: 513-325-2771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0101269358
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number35-057183
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberS8193
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number35.057183
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberM-16154
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: