Basic Information
Provider Information | |||||||||
NPI: | 1497887178 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 HOSPITAL RD STE 203 | ||||||||
Address2: |   | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104144740 | ||||||||
FaxNumber: | 4104144741 | ||||||||
Practice Location | |||||||||
Address1: | 110 HOSPITAL RD STE 203 | ||||||||
Address2: |   | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104144740 | ||||||||
FaxNumber: | 4104144741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2007 | ||||||||
LastUpdateDate: | 09/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | D0051814 | MD | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 6906-0005 | 01 |   | BLUE SHIELD DC | OTHER | 759211601 | 05 | MD |   | MEDICAID | 548502-06 | 01 |   | BLUE SHIELD OF MARYLAND | OTHER | 3263171 | 01 |   | AETNA US HEALTHCARE | OTHER | 352091 | 01 |   | MAMSI UNITED HEALTH CARE | OTHER |