Provider Demographics
NPI:1841226867
Name:JOHNSON, GARY D (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
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 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 DOUGLAS PIKE
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02917-1879
Practice Address - Country:US
Practice Address - Phone:401-618-5507
Practice Address - Fax:866-228-6713
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD080102084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1841226867Medicaid
MA110047410AMedicaid
RI007002094Medicare ID - Type Unspecified