Healthcare Provider Details

I. General information

NPI: 1003810862
Provider Name (Legal Business Name): CAMRON L JOHNSON PRIVITERA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BRAMBLETON AVE STE B
ROANOKE VA
24018-4642
US

IV. Provider business mailing address

5000 BRAMBLETON AVE STE B
ROANOKE VA
24018-4642
US

V. Phone/Fax

Practice location:
  • Phone: 540-200-8091
  • Fax: 540-799-7848
Mailing address:
  • Phone: 540-200-8091
  • Fax: 540-799-7848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102201592
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: