Basic Information
| Provider Information | |||||||||
| NPI: | 1013407360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | GUYLDA | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARD | ||||||||
| OtherFirstName: | GUYLDA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 60 CRITTENDEN BLVD APT 1226 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146204011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164731928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 913 CULVER RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146097141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5856545432 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2018 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 314636 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.