MEDICARE: DONALD J JOHANNESSEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0805X	Geriatric Psychiatry Physician	173503	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295800142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD J JOHANNESSEN MD

Provider Business Mailing Address
First Line	:	425 E 79TH ST
Second Line	:	SUITE 1E
City	:	NEW YORK
State	:	NY
Zip	:	10021-1037
Country	:	US
Telephone Number	:	212-249-4739
Fax Number	:	212-737-5574

Provider Business Practice Location Address
First Line	:	425 E 79TH ST
Second Line	:	SUITE 1E
City	:	NEW YORK
State	:	NY
Zip	:	10021-1037
Country	:	US
Telephone Number	:	212-249-4739
Fax Number	:	212-737-5574

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2007

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