Provider Demographics
NPI:1154372654
Name:JOHNSON, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:3015 WILLIAMS DR
Mailing Address - Street 2:STE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4623
Mailing Address - Country:US
Mailing Address - Phone:703-641-9133
Mailing Address - Fax:703-280-5098
Practice Address - Street 1:21351 RIDGETOP CIR
Practice Address - Street 2:STE 100
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6561
Practice Address - Country:US
Practice Address - Phone:571-434-0140
Practice Address - Fax:703-280-5098
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-057627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA300002314Medicare PIN
001069W85Medicare ID - Type UnspecifiedMC INDIVIDUAL PROVIDER #
G66314Medicare UPIN