Provider Demographics
NPI:1427114537
Name:JOHNSON, MATTHEW L (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
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 1:251 WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5617
Mailing Address - Country:US
Mailing Address - Phone:207-773-2828
Mailing Address - Fax:207-761-8150
Practice Address - Street 1:251 WOODFORD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5617
Practice Address - Country:US
Practice Address - Phone:207-773-2828
Practice Address - Fax:207-761-8150
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME0127562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME040224OtherANTHEM
ME108913OtherMARTIN'S POINT
ME100504700OtherOWCP
ME228090000Medicaid
ME100504700OtherOWCP
ME108913OtherMARTIN'S POINT
ME228090000Medicaid