Basic Information
| Provider Information | |||||||||
| NPI: | 1902886120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035160092 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 OLD ROLLINSFORD RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035160092 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 13402 | NH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3089171 | 05 | NH | MEDICAID |