Basic Information
| Provider Information | |||||||||
| NPI: | 1770070831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228068 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 E NATIONAL RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | VANDALIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453772100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375310113 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2018 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 34.014228 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.