Provider Demographics
NPI:1104878065
Name:JOHNSON, PAMELA CAROL (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:CAROL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 BRUCE PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-2852
Mailing Address - Country:US
Mailing Address - Phone:202-531-5033
Mailing Address - Fax:
Practice Address - Street 1:3742 10TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-1820
Practice Address - Country:US
Practice Address - Phone:202-269-0358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237027207P00000X, 207Q00000X
MDD44855207Q00000X
DCMD047674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00246395OtherRAILROAD MEDICARE
VA010150302Medicaid
VA1104878065Medicaid
VAVV3372AMedicare PIN
VA1104878065Medicaid
VA016818B00Medicare PIN