Provider Demographics
NPI:1972720399
Name:JOHNSON, ALBERT CEDRIC JR (MD)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:CEDRIC
Last Name:JOHNSON
Suffix:JR
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 1:7802 SAILORS LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-9606
Mailing Address - Country:US
Mailing Address - Phone:317-291-1031
Mailing Address - Fax:317-291-1031
Practice Address - Street 1:401 E 34TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3754
Practice Address - Country:US
Practice Address - Phone:317-926-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01019777A207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND69365Medicare UPIN
IND69365Medicare ID - Type Unspecified