Basic Information
| Provider Information | |||||||||
| NPI: | 1295712453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANSON | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 193 LOCUST ST | ||||||||
| Address2: | STE. 2 | ||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010602066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135848700 | ||||||||
| FaxNumber: | 4135841714 | ||||||||
| Practice Location | |||||||||
| Address1: | 193 LOCUST ST | ||||||||
| Address2: | STE. 2 | ||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010602066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135848700 | ||||||||
| FaxNumber: | 4135841714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 216773 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000026863 | 01 | MA | BMC | OTHER | 04-2817581 | 01 | MA | UNICARE/GIC | OTHER | 33435 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 04-2817581 | 01 | MA | NORTHEAST HEALTH DIRECT | OTHER | 04-2817581 | 01 | MA | PIONEER | OTHER | AA2007 | 01 | MA | HARVARD PILGRIM | OTHER | 04-2817581 | 01 | MA | NORTHEAST HEALTHCARE ALLI | OTHER | 04-2817581 | 01 | MA | PLAN VISTA | OTHER | 216773 | 01 | MA | CONNECITCARE | OTHER | 467270 | 01 | MA | TUFTS | OTHER | 04-2817581 | 01 | MA | PRIVATE HEALTHCARE SYSTEM | OTHER | 5306427001 | 01 | MA | CIGNA | OTHER | 0189651 | 05 | MA | MEDICAID | 04-2817581 | 01 | MA | CONSOLIDATED | OTHER | 04-2817581 | 01 | MA | GREAT-WEST | OTHER | J26513 | 01 | MA | BCBSMA | OTHER | 04-2817581 | 01 | MA | NORTH AMERCIAN PREFERRED | OTHER | 3410756 | 01 | MA | AETNA | OTHER |