Provider Demographics
NPI:1124843859
Name:JOHNSON, CARL JR
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:JOHNSON
Suffix:JR
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 1:116 N PACA ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1714
Mailing Address - Country:US
Mailing Address - Phone:240-501-2929
Mailing Address - Fax:
Practice Address - Street 1:116 N PACA ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1714
Practice Address - Country:US
Practice Address - Phone:240-501-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01914-24-A172V00000X
MDPR0937175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker