Provider Demographics
NPI:1699933903
Name:JOHNSON, WILLIAM A IV (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:JOHNSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 HARROUN RD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2182
Mailing Address - Country:US
Mailing Address - Phone:419-824-1399
Mailing Address - Fax:419-824-1772
Practice Address - Street 1:5300 HARROUN RD
Practice Address - Street 2:SUITE 118
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2182
Practice Address - Country:US
Practice Address - Phone:419-824-1399
Practice Address - Fax:419-824-1772
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125049506207Y00000X
OH35095934207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3082597Medicaid
OH3082597Medicaid
OHJO4299182Medicare PIN