Provider Demographics
NPI:1124264148
Name:JOHNSON, ROMAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 CHAMBERS ST APT 14C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-1991
Mailing Address - Country:US
Mailing Address - Phone:603-381-4194
Mailing Address - Fax:
Practice Address - Street 1:41 DIVISION ST
Practice Address - Street 2:APT. 5 FA
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-6700
Practice Address - Country:US
Practice Address - Phone:603-381-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250497208D00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice