Provider Demographics
NPI:1992791420
Name:JOHNSON, WILLIAM GILL
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GILL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18710 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-4026
Mailing Address - Country:US
Mailing Address - Phone:717-723-1769
Mailing Address - Fax:
Practice Address - Street 1:18710 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-4026
Practice Address - Country:US
Practice Address - Phone:717-723-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01120878Medicaid
NY01120878Medicaid
NY97525Medicare ID - Type Unspecified