Provider Demographics
NPI:1902079015
Name:JOHNSON, EDWARD ALEX (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ALEX
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 REDGATE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 REDGATE AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1515
Practice Address - Country:US
Practice Address - Phone:757-668-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249802208000000X
NC2013-02344208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC186RLOtherBCBS NC
SC315974Medicaid
NC1902079015Medicaid
NC186RLOtherBCBS NC
NC1902079015Medicaid