Healthcare Provider Details

I. General information

NPI: 1457674954
Provider Name (Legal Business Name): DEGRAFT-JOHNSON MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 6196 AGAPE MEDICAL CENTER
KINGSHILL VI
00850-9826
US

IV. Provider business mailing address

RR 1 BOX 6196 AGAPE MEDICAL CENTER
KINGSHILL VI
00850-9826
US

V. Phone/Fax

Practice location:
  • Phone: 340-772-2000
  • Fax: 340-778-9798
Mailing address:
  • Phone: 340-772-2000
  • Fax: 340-778-9798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number1579
License Number StateVI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1578
License Number StateVI

VIII. Authorized Official

Name: DR. LATIFA DEGRAFT-JOHNSON
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 612-669-5048