Provider Demographics
NPI:1134399025
Name:JOHNSON, CHARISSE D (MD)
Entity type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 FLORENCE AVE STE 233
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8048
Mailing Address - Country:US
Mailing Address - Phone:574-855-4575
Mailing Address - Fax:
Practice Address - Street 1:229 FLORENCE AVE STE 233
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8048
Practice Address - Country:US
Practice Address - Phone:574-855-4575
Practice Address - Fax:833-314-0410
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068390A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200987950Medicaid
IN000000666329OtherBCBS MEMORIAL CHILDREN'S HOSPITAL
IN000000666897OtherBCBS BMG MAIN ST
IN200987950Medicaid
INM400022136Medicare PIN