Provider Demographics
NPI:1104236850
Name:JOHNSON, SHAKEVIA V (MD)
Entity type:Individual
Prefix:
First Name:SHAKEVIA
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAKEVIA
Other - Middle Name:VONTA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:801 ALBANY ST
Mailing Address - Street 2:FL G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CENTER PLACE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:617-414-5520
Is Sole Proprietor?:No
Enumeration Date:2014-05-03
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN556032084P0800X
MS248412084P0800X
MA2869062084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110171775AMedicaid