Provider Demographics
NPI:1902817307
Name:JOHNSON, JEFFREY J (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
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 1:173 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3508
Mailing Address - Country:US
Mailing Address - Phone:603-788-4911
Mailing Address - Fax:603-788-5031
Practice Address - Street 1:173 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NH
Practice Address - Zip Code:03584-3508
Practice Address - Country:US
Practice Address - Phone:603-788-4911
Practice Address - Fax:603-788-5031
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0008782207P00000X
NH10082207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3073610Medicaid
VT0VN0703Medicaid
NHVN070302Medicare PIN