Provider Demographics
NPI:1144264276
Name:JOHNSON, REGINA (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:LAWLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4851 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6715
Mailing Address - Country:US
Mailing Address - Phone:303-425-0300
Mailing Address - Fax:303-432-5790
Practice Address - Street 1:4851 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6715
Practice Address - Country:US
Practice Address - Phone:303-425-0300
Practice Address - Fax:303-432-5790
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO420532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99848Medicare UPIN
COC535858Medicare ID - Type Unspecified