Provider Demographics
NPI:1902886120
Name:JOHNSON, JEFFREY RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
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 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-516-0092
Mailing Address - Fax:
Practice Address - Street 1:15 OLD ROLLINSFORD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2868
Practice Address - Country:US
Practice Address - Phone:603-516-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13402207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3089171Medicaid
NH3089171Medicaid