Provider Demographics
NPI:1891736864
Name:JOHNSON, PATRICIA LYNN (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1953
Practice Address - Country:US
Practice Address - Phone:317-873-8900
Practice Address - Fax:317-873-2655
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044746A207V00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000383685OtherANTHEM PROVIDER ID NUMBER
IN000001073792OtherANTHEM PTAN
IN264430556OtherMEDICARE PTAN
000000001367OtherMPLAN PROVIDER ID NUMBER
IN200167490Medicaid