Provider Demographics
NPI:1104241595
Name:JOHNSON, CODY REID
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:REID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 BROOM DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-3124
Mailing Address - Country:US
Mailing Address - Phone:440-317-4700
Mailing Address - Fax:
Practice Address - Street 1:8901 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-2197
Practice Address - Country:US
Practice Address - Phone:440-317-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-22
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012587412085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty