Provider Demographics
NPI:1124343892
Name:JOHNSON, ALICE HOANG (MD)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:HOANG
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:THE
Other - Last Name:HOANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7763531
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3 AUDUBON PLAZA DR
Practice Address - Street 2:LL-2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1300
Practice Address - Country:US
Practice Address - Phone:502-636-8095
Practice Address - Fax:502-636-8097
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY45905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000829388OtherANTHEM - NCMA
KY50053203OtherPASSPORT
KY149326OtherSIHO
KY7100167540Medicaid
KY50053203OtherPASSPORT