Healthcare Provider Details

I. General information

NPI: 1902079015
Provider Name (Legal Business Name): EDWARD ALEX JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 REDGATE AVE
NORFOLK VA
23507-1515
US

IV. Provider business mailing address

811 REDGATE AVE
NORFOLK VA
23507-1515
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101249802
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: