Healthcare Provider Details

I. General information

NPI: 1154372654
Provider Name (Legal Business Name): LISA JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21351 RIDGETOP CIR STE 100
STERLING VA
20166-6561
US

IV. Provider business mailing address

3015 WILLIAMS DR STE 200
FAIRFAX VA
22031-4623
US

V. Phone/Fax

Practice location:
  • Phone: 571-434-0140
  • Fax: 703-280-5098
Mailing address:
  • Phone: 703-641-9133
  • Fax: 703-280-5098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101-057627
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: